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A Humanities Journal for Medicine 
and the Health Sciences 

Simulation in Medical Education 


Digitized by the Internet Archive 

in 2011 with funding from 

CARLI: Consortium of Academic and Research Libraries in Illinois 


A Humanities journal for Medicine and the Health Scieucet 
Volume 13 ♦ Number 2 ♦ Autumn 1997 


Simulation in Medical Education 

2 Introduction 

Howard S. Barrows, Guest Editor 

5 Following the Threads of an Innovation: The History of 
Standardized Patients in Medical Education 
Peggy Wallace 

29 Sim One— A Patient Simulator Ahead of Its Time 
Stephen Abrahamson 

42 The Visible Human: A New Language for Communication in 
Health Care Education 
Victor M. Spitzer 

49 Medicine Beyond the Year 2000 
Richard IVI. Satava and Shaun B. Jones 

65 Use of a Mock Trial Simulation to Enhance Legal Medicine 
Education for Medical Students 
Theodore R. LeBlang 

76 Picture Credits 

Published by die Department 
of Medical Humanities 
Soudieni Illinois Univeisity 
School ot Medicine 


Johns. HMei. Jr., Editor 
Phillip V. Davis, Deputy Editor 
Mai7 Ellen McEUigott, 

Managing Editor 
Sarali L. Peters, 

Editorial Assistant 
Jean L. Kirchner, Editorial 


Department Of Medical 

Theodore R. LeBlang, Chair 
M. Lynne Cleverdon, 

Assistant to the Chair 
Barbara Mason, Curator, 

The Pearson Museum 
Jean L. Kirchner, 

Subscription Manager 

Copyright 1997 by die Board of 
Trustees of Southern Illinois 
University-. ISSN No. 0882-7447 


Simulation in Medical Education 

Howard S. Barrows, Guest Editor 

This issue documents more than the 
range of simulations available in 
medical education. It also documents the 
remarkable resistance of medical faculty to 
new developments in education. Too often, 
they leave behind the forward-looking 
questioning, scientific approach they use in 
their clinical care and research roles and 
regress to entrenched, unquestioned tradi- 
tion in their teaching roles. 

Simulations support both the develop- 
ment and assessment of complex perfor- 
mance skills in realistic contexts, without 
risk and undo cost. Simulations can be 
manipulated in ways not possible in the 
real world to achieve a variety of educa- 
tional objectives. Problems undertaken by 
the learner can be repeated until mastered. 
Activities undertaken by the learner in the 
simulation can be interrupted for feedback 
and discussion. The challenge of the task 
can be simplified or complicated. The 
stress of time limitation and conflicting 
demands can be amplified or attenuated. 
The same task or challenge can be given to 
each student, repeated without the varia- 
tion that occurs in the real world. The task 
appropriate to level of learning can be 
presented to the learner at the most appro- 
priate time in an educational program. 

The teaching that goes on in many 
schools today resembles what was done 

centuries ago. The educational conser- 
vatism of medical faculties is well charac- 
terized in their adoption of simulations. 
Educational innovations in medical educa- 
tion have great difficulty getting a 
foothold. Both the standardized patient 
technique described in this issue by Peggy 
Wallace and the simulated anesthesia 
patient described by Stephen Abrahamson 
were developed over a quarter of a century 
ago. Their adoption was inhibited for 
many years by the prevailing attitude of 
academic physicians in this country and in 
Europe that there were always patients 
available for practice by students and 
residents— simulations were an unneeded 
expense and obviously unreal. Medical 
care has changed drastically over the last 
fifteen years, and the usual "charity" 
patient is no longer a limitless supply as 
was the case when these simulations were 
developed. In many settings, the shortage 
of patients available for practice by 
students has been the stimulus for an 
interest in simulation— not concern for the 
well-being of patients. The need for 
standardization and availability of appro- 
priate patient problems for skill assessment 
and the discomfort and risk to patients 
during student and resident learning were 
never compelling arguments for most 
medical teachers. 

CADUCEUS ♦ Autumn 1997 ♦ Vol. 13, No. 2 

The torturous and slow course of 
standardized patient development is well 
chronicled by Wallace. It is a testimony to 
persistence by those few who saw the 
potential value of the technique. Now, the 
standardized patient is ubiquitous in 
medical education. Medical educators are 
finding valuable new ways of not only 
employing the technique but also 
enhancing its value, reliability, and validity. 
It is impossible now for many to imagine 
that there could have been objections or 
reservations about using standardized 
patients— the need is obvious. 

Abrahamson's story of Sim One reads 
like a tragedy. Sim One was not only inhib- 
ited, it was destroyed by those unable to 
appreciate or care about its unique and 
humane value to the care of patients, 
despite remarkable persistence by its 
innovators. As you read the evaluations 
that were carried out on Sim One's effec- 
tiveness you can only imagine the lives and 
suffering it saved— the dummy could be 
injured and die many times as students 
learned. Now that the employment of 
space-age computer technology has made 
incredible simulations prevalent, it might 
be difficult to believe the short-sightedness 
of those in the Los Angeles County 
Hospital who did let Sim One die, not of 
poor skills in intubation and anesthesia but 
of neglect. Abrahamson and his cohorts 
used state-of-the-art postwar technology 
thirty years ago to create an incredibly 
realistic and responsive patient dummy 
that could challenge and record the wide 
variety of skills required in giving 
anesthesia. They were way ahead of their 
time! A few months ago I sent 
Abrahamson a clipping from a newspaper 
in Cambridge (UK) describing a clever new 
idea in medical education that was devel- 
oped there— a dummy that could be used 

for training in anesthesia. 

Victor M. Spitzer's paper on the Visible 
Human Project introduces anatomical 
simulations of the human body that can be 
viewed from any aspect and cut in any type 
of section. The viewer can travel through 
the body in any path through sections, 
construct three-dimensional images, 
identify systems and organs within their 
whole body contexts, and carry out 
surgical procedures and interventions with 
tactile feedback from the structures 
punctured or cut. The educational implica- 
tions and possibilities of this ability already 
boggles the mind, yet Spitzer hints of even 
more. He suggests future integration of 
physiological phenomena into the anatom- 
ical data, adding an understanding of 
tissue function to the already incredible 
displays. His other suggestion for future 
incorporation of similar embryonic- 
through-geriatric anatomy with the adults 
he now has adds the fourth dimension of 
time to those three-dimensional displays. 
Not content with that, he hints that by 
incorporating other developing data we 
may eventually travel back phylogenetically 
to look at human evolution. He has a great 
vision, and the educational implications 
are almost beyond comprehension. 

The paper by Richard M. Satava and 
Shaun B. Jones is an exciting, comprehen- 
sive update on where computer technology 
has taken us with the simulations created 
in the world of virtual reality. What is 
being accomplished seems almost 
unbelievable. The simulations not only 
allow for practice and assessment but are 
designed to enhance surgical technology 
applied to patients. I thought that perhaps 
times had changed in the attitude of 
medical faculty about simulations, but then 
I heard about a recent conference where 
virtual surgery simulations were presented. 

Howard S. Barrows 3 

Portrait of Lynn Taylor, one of the very 
first simulated patknts trained by 
Howard Barrows for instruction of 
neurology clerks at the Los Angeles 
County General Hospital. In his 1971 
volutrw introducing the use of simulated 
patients in medical education, the author 
notes that artists' models as well as 
amateur and professional actors and 
actresses can be excellent groups to draw 
from in recruiting simulated patients. He 
advises those starting a program to 
inquire at the local drama department or 
a local amateur or professional acting 
society about potential interest, but to 
recognize that the most important quali- 
ties of a successful simulated patient are 
intelligence, a flair for personal acting 
and a willingness to be demonstrated, 
interviewed, and examined as a patient. 
The portrait is the work of Phyllis 
Barrows who, at the time of painting 
was unaware that the model was one of 
the pioneer standardized patients then 
being trained by her husband. 

A number of surgeons at 
the conference were up 
in arms about the sugges- 
tion that their skills 
could be improved upon, 
if not replaced, by such 

Theodore R. LeBlang 
describes the simulation 
of an actual courtroom 
trial involving important 
medicolegal issues for 
the education of medical 
students. It is compelling 
for students as medical 
faculty and local promi- 
nent legal professionals 
simulate the people 
involved. It's far more 
realistic and meaningful 
than either reading the 
case or watching a televi- 
sion demonstration. It 
would be interesting to 
see if down the line the 
medical students could 
be actively involved and 
play the medical roles in 
the courtroom drama— so 
much more might be 
learned about prepara- 
tion for those roles they 
might have to play in 
their clinical lives. 

As these collected 
papers show, the stage 
has been set in medical 
education for teachers to 
value simulations for 
their educational value in 
facilitating skill develop- 
ment and direct assess- 
ment of performance 
competency without risk 

and undue cost. Perhaps some health 
science journal a decade into the future 
will show ingenious simulations developed 
in a more accepting climate for educa- 
tional innovation. 

HOWARD S. BARROWS is presently the Chair of the 
Department of JVIedical Education at Southern Illinois 
University School of Medicine. In the early sixties, 
while directing the neurological service and 
residency program of the Los Angeles County 
Hospital, he developed the technique of training 
people to simulate patients (simulated patients, 
standardized patients) for teaching and assessment 
in medical school. In the seventies, he developed the 
technique of using standardized patients for 
teaching, particularly in problem-based learning. In 
the early eighties, he pioneered the development of 
the multiple-station, clinical practice examinations 
using standardized patients to assess the clinical 
competencies of medical students. Through many 
publications, demonstrations, consultations, and 
workshops he has encouraged the dissemination of 
the use of standardized patients in medical and 
health science schools. He is the author of The 
Tutorial Process; The Clinical Practice Exam: Six- 
Year Summary, What Your Tutor May Never Tell You: 
A Medical Studerit's Guide to Problem-Based 
Learning; Developing Clinical Problem-Solving 
Skills: A Guide to More Effective Diagnosis and 
Treatment, and Practice -Based Learning: Problem- 
Based Learning Applied to Medical Education. The 
National Board of Medical Examiners honored him as 
the first recipient of the John Hubbard Award. 

4 Introduction 

Following the Threads of an Innovation: 
The History of Standardized Patients in 
Medical Education 

Pegg)' Wallace 


The emblem of the medical profession, the 
caduceus, was given to Hermes, messenger 
of the gods, by Apollo, the God of 
Medicine, who empowered the winged 
staff to bring peace out of conflict. 
Skeptical, Hermes tested Apollo's declara- 
tion by planting the golden winged rod 
between two fighting serpents at which 
point they both entwined themselves in 
opposite directions onto the staff, ending 
up facing one another in reconciliation. 
That totality, the caduceus, is a symbol of 
integration. It is the weaving of conflicting 
elements together into wholeness, no 
longer "either-or," but rather "both-and": 
science and art, teaching and testing, 
knowledge and compassion, theory and 
practice, technology and the person, 
doctor and patient, illness and recovery. It 
refers back to the method of Hippocrates, 
the Father of Medicine, and to that of 
Apollo's son, Asklepios, the God of 
Healing. It goes back to the Oath of 
Hippocrates taken by all who are about to 
embark upon the practice of medicine. In 
addition to a code of ethics by which the 
new physician will live in the fellowship of 
the medical profession, the Oath honors 

the relationship and responsibilities of 
student to teacher/ teacher to student. 

Underneath the history that is about to 
unfold are many untold stories of the 
teachers and the students, the famous and 
the unknown, whose endeavors, trivial and 
distinguished, hold the wisdom of the 
serpents on the staff of the innovation. 
After thirty years, the standardized patient 
now supports that knowledge and holds in 
the caduceus's paired wings, the inspira- 
tion for learning from the immediacy of 
the human encounter. The student and the 
teacher coming together to discover the 
wisdom and the meaning of the profession 
that chooses them. 


The term standardized patient (SP) has gone 
through many metamorphoses as the 
process itself has been refined since its 
inception in 1963. There have been many 
other names attempting to describe this 
phenomenon: programmed patient, 
patient instructor, patient educator, profes- 
sional patient, surrogate patient, teaching 
associate, and— the more generic term— 
simulated patient. What all of these terms 
are referring to is a person who has been 

The caduceus 

CADUCEUS ♦ Autumn 1997 ♦ Vol. 13, No. 2 

carefully trained to take on the characteris- 
tics of a real patient in order to provide an 
opportunity for a student to learn or be 
evaluated on skills firsthand. While working 
with the standardized patient, the student 
can experience and practice clinical 
medicine without jeopardizing the health 
or welfare of real, sick patients. The value 
is in the experience of working with a 
patient. It takes the process of learning a 
step beyond the books and away from 
reliance on paper and pencil tests. It puts 
the learning of medicine in the arena of 
veritable clinical practice— not virtual 
reality, but veritable reality— as close to the 
truth of an authentic clinical encounter as 
one can get without actually being there, 
because there is a living, breathing, 
responding human being to encounter. 

The expression "standardized patient" 
was coined by the Canadian psychometri- 
cian Geoffrey Norman, who was looking 
for a designation that would capture one 
of the technique's strongest features, the 
fact that the patient challenge to each 
student remains the same.^ The term was 
adopted and generally accepted in the 
1980s, when the focus of medical educa- 
tion research using simulated patients 
turned sharply toward research in clinical 
performance evaluation. The standardized 
patient offers the student an opportunity 
to come face to face with the totality of the 
patient, with his "stories," physical 
symptoms, emotional responses to his 
illness, attitudes toward the medical profes- 
sion, stresses in coping with life, work and 
his family— in other words, everything a 
real patient brings to a clinician, overt and 
hidden (except the necessity of actually 
"making the patient better"), allowing the 
student to go about the process of unfolding 
all that he feels he needs to know from the 

veritable interaction with the patient in 
order to assist that person to heal. 

The Threads: The Innovators 

The 1960s 

Today, as we enter the new millennium, 
the standardized patient has become one 
of the most pervasive and highly touted of 
the new methodologies in medical educa- 
tion. But it was certainly not always so. The 
standardized patient was anything but a 
welcome and readily accepted educational 
tool, especially in the early days. Its accep- 
tance was tentatively held at arms length, 
criticized as too touchy-feely, too expen- 
sive, too "Hollywood." Perhaps the last 
charge was made because the first 
simulated patient was born, if not in 
Hollywood, very close by, in Los Angeles 
at the University of Southern California 

The father of this innovation in medical 
education and the most convincing herald 
in the history of the use of standardized 
patients is the neurologist and medical 
educator Howard S. Barrows, who gave 
birth to the first simulated patient in 1963 
when he was teaching third-year neurology 
clerks at USC. It was not an auspicious 
beginning. In fact, for the whole of the 
time that Barrows taught at that institu- 
tion, "No one else at USC was even inter- 
ested in using it. . . . Nobody was even 
interested in trying it."^ In those early days, 
Barrows was often invited to speak about 
neurological subjects, but frequently was 
requested not to talk about simulated 
patients. In fact, he was seen as doing 
something quite detrimental to medical 
education, maligning its dignity with 
"actors." As soon as the Associated Press 
got hold of the idea, it was promoted in 
the popular press by such headlines as: 

6 Standardized Patients in Medical Education 

"Hollywood Invades USC Medical 
School"^^ and such descriptions of 
simulated patients as: "Scantily clad models 
are making life a little more interesting for 
the USC medical students."^ This made it 
all the more difficult for Barrows to 
convince his medical colleagues that the 
technique he was using to teach medical 
students was a legitimate educational tool. 
Their resistance persisted even after the 
1964 publication of the first article on 
simulated patients, "The Programmed 
Patient: A Technique for Appraising 
Student Performance in Clinical 
Neurology" in the Journal of Medical 
Education.^ Barrows's coauthor on this 
landmark article was Stephen 
Abrahamson, director of the USC Division 
of Research in Medical Education. 

The USC dean received complaints from 
medical schools all over the country but 
just decided to ignore them. However 
Barrows, in an attempt to legitimize the 
work to which he was becoming so 
committed, replied individually to the 
dean or associate dean at every single one 
of the complaining medical schools, 
sharing copies of the Journal of Medical 
Education article. 

Barrows went to such trouble and 
persisted in using the simulated patient in 
his clerkship for no other reason than the 
fact that "it was working." Students loved 
the technique, and, as he said, "I was 
learning things about those students I 
would have never found otherwise."^ 
Barrows was searching for an alternative to 
the traditional method of evaluating 
students on their clinical clerkships, an 
unsatisfactory procedure that persists even 
today." When faculty got together at the 
end of a clerkship, Barrows remembers the 
conversation going something like this: 

"Let me look at that student's picture. . . . 
Well, I think I remember him." Typically, 
according to Barrows, most clerks received 
satisfactory or better evaluations. "And I 
knew it was because of the way they 
combed their hair or how neatly they 
dressed or if they said 'Yes sir' and 'No 
sir.'"*^ Almost never was there a student 
whose clinical skills were evaluated as 
unsatisfactory because the faculty almost 
never directly observed a student with 
patients. In fact, until the advent of 
standardized patients, there was no objec- 
tive clinical measure by which to evaluate 

As with most innovations, several events 
occurred in Barrows's experience that 
planted the seeds for the birth of the first 
simulated patient. In 1959-1960, during 
his last year as chief resident in neurology 
at the New York Neurological Institute, 
Columbia-Presbyterian Medical Center, 
Barrows worked on the service of a 
professor by the name of David Seegal 
who "would sit and watch every single 
medical student work up a patient 
completely from beginning to end. That 
took at least an hour for each student." 
When Barrows asked him why he was 
spending so much time doing this, Seegal 
responded: "Nobody in medical school 
ever watches these fledgling medical 
students. . . ."'" Barrows realized that 
because of Seegal's commitment to direct 
observation of the students, he was finding 
a number of skills on which the students 
could improve because they had not 
known they were doing them incorrectly. 

The other seminal event occurred 
around the same time when Barrows, who 
was responsible for finding neurological 
patients for the board examination in 
psychiatry and neurology, ran into Sam, a 

Peggy Wallace 7 

patient who had been the subject for this 
examination a number of times: 

Following the examination, the director of the 
Montefiore neurology service made rounds on 
his patients to see how they had tolerated the 
numerous examinations they had had to 
undergo during the examination. He inter- 
viewed a patient known to ever)'body as Sam, 
who had syringomyelia. When asked about the 
examination, Sam remarked that there had 
been no particular problem except with the 
physician who had examined him last. Sam 
indicated that that physician had been quite 
hostile and had performed a very uncomfort- 
able neurological examination. The director 
said that he was sorry to hear that, but Sam 
said, "Don't worry, I fixed him— I put my 
Babinski on the other foot and changed my 
sensory findings."" 

Barrows's first full-time faculty position 
was in the Department of Neurology at 
use. It was there, in the early 1960s, that 
he met Stephen Abrahamson, the 
renowned medical educator who had just 
been recruited to establish one of the first 
departments of medical education in the 
country. They developed a relationship 
that inspired the exploration of a number 
of innovative educational methodologies. 
To illustrate, shortly after he arrived at 
use, Abrahamson introduced the 8mm 
single-concept film cartridge, one of the 
latest innovations in media, at a conference 
on medical education in Los Angeles. 
Barrows immediately sensed its potential. 
He saw how he might be able to use it in 
teaching the normal neurological examina- 
tion by documenting each part of the 
exam on a series of four-minute, single- 
cartridge film loops. Needing a person 
who was completely comfortable being the 
subject for such a demonstration. Barrows 
went to the USC Art Department and hired 
an artists' model. Rose McWilliams. Those 

8mm cartridges were used by students to 
learn the neurological exam on the clerk- 
ship, and as a refresher for residents who 
might want to review a specific part of the 
exam before working with a patient. 

However, Barrows still had the perennial 
clerkship evaluation dilemma. "I had the 
film loop and I had Rose. And suddenly I 
thought, 'I wonder, if I could teach Rose, 
like Sam, to have a neurological 
problem. '"'2 

In order to evaluate the clerks, Barrows 
needed a case about which he knew every- 
thing—all the signs, all the symptoms. He 
needed a case that could be reproduced 
for every single clerk in exactly the same 
way, and he needed someone who had the 
time and the knowledge to record what 
happened in each encounter with the 
patient. Seegal's detailed understanding of 
the clinical competence of his clerks and 
Sam's ability to create his own simulated 
findings inspired Barrows to create Patty 
Dugger, the first standardized patient case, 
which was performed by McWilliams. 

Patty Dugger, a paraplegic woman with 
multiple sclerosis, was based on a Los 
Angeles County Hospital patient. It is a 
case that is so impressive in its simulated 
findings that Barrows still continues to use 
it in demonstrations around the country. 
Others have found this case so rich that it 
has shown up throughout the years in 
various learning, assessment, and research 
projects, and is, even today, still being 
experienced by some students in their 
clinical clerkships at a number of medical 

After the case was developed, the 
question of how to actually do the evalua- 
tion arose. "Should I peek through a 
drape, or what should I do? I finally 
decided that I would make [a] checklist 
that Rose would fill out afterwards. "^^ 

Standardized Patients in Medical Education 

Barrows monitored Rose and the students 
from time to time, but it was Rose who was 
primarily responsible for recording what 
happened with each student during every 

So the birth of the standardized patient 
came out of a need for a more rigorous 
method to evaluate the clinical skills of 
third-year medical students. The method- 
ologies designed by Barrows, from what he 
called a "pretty primitive" first effort, are 
the source of the procedures currently 
being refined by the National Board of 
Medical Examiners (NBME) and the 
Educational Council for Foreign Medical 
Graduates (ECFMG) for their anticipated 
clinical competence exams, to be included 
as part of licensure, sometime around the 
turn of the millennium. 

Barrows was learning all kinds of thiiigs 
about the students on his clerkship that he 
knew were absent on the other clerkships, 
but none of the faculty were willing to 
change. Abrahamson had helped him legit- 
imize the simulated patient technique 
outside of USC, but Barrows was still 
meeting with such total resistance from 
neurologists that he began to think about 
other options. "Here I am a neurologist," 
he recalled, "and my interest is in teaching 
neurology. I had a tool. Neurologists were 
not interested in that tool [so] I eventually 
became interested in working with people 
in other fields. I remember deliberately 
making that decision when I was at 

After having spent a sabbatical year in 
Canada in the late 1960s, Barrows left USC 
in 1971 to become one of the founding 
faculty at McMaster University in Hamilton, 
Ontario, "because it was a much more 
understanding climate. "^^ McMaster had a 
new medical school, the first with an entirely 
problem-based learning (PBL) curriculum. 

The 1970s 

Along with his use of 
simulated patients to evaluate 
medical students, Barrows 
began to see the value of 
simulated patients in teaching 
and research. At the same 
time, he started reaching out 
to other practicing physicians 
by designing workshops to 
help them improve their 
neurological skills. Barrows's 
underlying philosophy in 
these workshops was experi- 
ential learning, learning by 
doing and receiving imme- 
diate feedback. 

Primary among a series of 
such seminal workshops 
during the 1970s, that relied 
heavily on the use of simu- 
lated patients, were the "Bed- 
side Clinics in Neurology," 
sponsored by the American 
Medical Association (AMA).^*^ The day 
before the workshop. Barrows would 
bring in five prominent neurologists from 
around the country (who would serve as 
tutors for the workshop participants) and 
an equal number of simulated patients. 
The SPs were not only trained to perform 
several neurological cases, but they were 
also trained to simulate typical continuing 
medical education participants, such as 
"the one who isn't interested, the one 
who's always asking incredible questions, 
interfering with everybody else."^^ This 
gave the neurologist-tutors an opportu- 
nity to practice and learn how to work 
effectively with the simulated patients and 
the neurological cases as well as with the 
types of physicians with whom they might 
find themselves working the following 

Photograph taken at the Los 
Angeles County/University of 
Southern California Medical 
Center of Howard S. Barrows 
training the first "Patty Dugger" 
(Rose McWilliams) to produce a 
Babinski response when her foot is 
being scratched 

Peggy Wallace 9 

During the workshop, each neurologist- 
tutor was assigned a group of five or six 
physicians. The challenge was "to make his 
group of physicians perfect by the end of 
the day."'^ Each group would start with 
one simulated patient and work through a 
case using the "time in-time out" 
technique. "Time in-time out" was first 
used by Barrows at McMaster to enhance 
small group teaching. By calling a "time 
out," the interview was "put on hold," 
allowing the students an opportunity to 
discuss among themselves any number of 
issues that had arisen in the encounter as 
well as to brainstorm where they might like 
to take the interview when they went back 
to "time in" with the simulated patient. 

During the Bedside Clinics, it was the 
responsibility of the tutors to detect the 
problems the individuals in their groups 
were having and then focus their next 
simulated patient experiences in those 
areas. As Barrows pointedly stated, "If you 
ask most physicians what they don't know, 
they don't know they don't know what 
they don't know."'^ This premise is true 
for students of all ages, no matter how 
experienced they are. If the students 
always knew what they didn't know, they 
could probably figure out how to learn it 
on their own. 

In addition to Barrows's strong belief in 
the efficacy of experiential and participa- 
tory learning, there is another principle in 
his educational philosophy that sheds light 
on his approach. As much as possible. 
Barrows believes that the student should be 
given an opportunity to learn in the same 
manner as the student is going to practice. 
The germ of that principle can be traced to 
some work that Barrows did at Michigan 
State University (MSU), in the early 1970s, 
with Milliard Jason, Arthur Elstein and Lee 
Shulman of the Office of Medical Research 

and Development (OMRAD). 

After seeing a demonstration of the 
Patty Dugger case at the annual meeting of 
the Non-Group Society (now known as the 
Society of Directors of Research in Medical 
Education [SDRME]), Hilliard Jason, the 
director of OMRAD, was so impressed 
with the technique that he established a 
simulated patient program in the first two 
years of medical school at MSU. He 
designed four "difficult patient" cases for 
the students to experience: a hostile 
patient, a seductive patient, a patient from 
another culture, and a patient who hated 
physicians. During the student interviews, 
two cameras simultaneously recorded 
individual shots of the student and the 
simulated patient. These close-up images 
were electronically placed side-by-side in a 
single, split-screen image so that when 
Jason later reviewed the videotaped 
encounter with the student, the actions 
and the reactions in both the student and 
the simulated patient could be observed 
simultaneously. It was one of the first of 
many educational applications inspired by 
Barrows's simulated patient work. 

Shortly thereafter, Shulman invited 
Barrows to develop a couple of simulated 
patient cases that he and Elstein wanted to 
use, on a new research project conceived 
by Hilliard Jason, to try to determine how 
physicians solve problems. 2*^ They were 
using stimulated recall, a technique devel- 
oped by a colleague, the noted psycholo- 
gist Norman Kagan. Elstein and Shulman 
encouraged Barrows personally to go 
through their research protocol using this 
technique. The physician was encouraged 
to do his usual workup of a patient while 
being videotaped. The researchers immedi- 
ately reviewed the encounter with the 
physician, stopping and starting the tape, 
asking the physician to recall what was 

10 Standardized Patients in Medical Education 

going on in his mind at various moments 
in the encoimter. 

It was such an enlightening experience 
for Barrows that it inspired him to use 
stimulated recall to explore the thinking 
process of other practicing neurologists, 
and then to do the same with his residents 
and students. What struck Barrows when 
he experienced the stimulated recall at 
MSU was that he was not teaching in the 
same way that he was practicing. As he 

So many faculty teach students to do a 
complete history and complete physical. There 
is no such thing. Ask every question, do every- 
thing on physical, there is no such thing. And 
when they get into real life, they're lucky if 
they have twenty minutes with a patient. And if 
they're in an emergency, they're lucky if 
they've got five minutes. You can't ask ever) 
question. So they have to know the right 
questions to ask.'-' 

The discoveries about clinical reasoning 
were so potent for Barrows that he 
changed his approach to education, no 
longer teaching students the "complete" 
history and physical exam, the way he was 
taught. Instead, he provided the students 
with the infinite possibilities a patient 
provides by letting the students ask 
anything they wanted, either in direct 
interaction with a simulated patient or by 
building that kind of flexibility into written 
patient problems. In this way, the student 
learned what questions did— and what 
questions did not— have a "payoff" in 
relation to their hypotheses. The goal was 
not to memorize an exhaustive list of 
questions and physical exam maneuvers. It 
was to guide the students into learning 
what were the appropriate questions and 
maneuvers while helping the students 
think through their assumptions of what 
might be wrong with the patient. 

While at McMaster, Barrows provided 
another significant contribution by 
expanding the potential use for the 
simulated patient, at the same time 
affirming the authenticity of the SP perfor- 
mance methodolog)'. One complaint often 
heard about the formalized assessment of 
clinical skills revolves around the question 
of physician performance— not in the 
examination setting, but in the day-to-day 
clinical practice setting. In other words, 
how realistic would an SP appear to the 
physician unaware that the patient is 
simulating a case? In one McMaster study, 
the simulated patients were scheduled in 
the physician's office unannounced. The 
skills and quality of the physician's perfor- 
mance were then determined by 
comparing the reports made by the 
standardized patients, who were 
undetected as simulations, to the physi- 
cian's office records.-- This study has 
inspired a number of similar studies 
throughout the intervening years. 

Besides Barrows, there are a number of 
other threads that weave together to shape 
the history of standardized patients. Also 
significantly responsible for establishing 
the standardized patient as both a credible 
teaching methodolog)' and a reliable evalua- 
tion tool is the pediatrician Paula Stillman. 
There have been a number of organizations 
as well: the Josiah Macy, Jr. Foundation, the 
Liaison Committee on Medical Education 
(LCME) of the American Medical 
Association, the National Board of Medical 
Examiners (NBME) and the Educational 
Council for Foreign Medical Graduates 
(ECFMG). These organizations, which have 
been primarily responsible for the firm 
establishment of this technique in medical 
schools throughout the United States, as 
well as Stillman and a number of other less 
well-known clinician educators, have all 

Peggy Wallace 1 1 

been influenced by Barrows's continuing 
enthusiasm, persistence and effectiveness 
in advocating the use of the standardized 
patient over the past three decades. 

Contributions of Paula Stillman 

In the early 1970s, when she was the 
pediatric clerkship director at the 
University of Arizona in Tucson, Paula 
Stillman started using simulated mothers 
as a technique for teaching interviewing 
skills. She was inspired by work being done 
at MSU by another pediatrician, Ray 
Heifer, who had trained "programmed 
mothers" to give histories of common 
pediatric complaints. Heifer, no doubt 
influenced by the stimulated recall 
research at MSU, employed graduate 
students to review the tapes of each 
medical student encounter, then code their 
behaviors into some twenty-five 
categories.-^ Stillman found the process 
complicated and cumbersome. When she 
returned to Arizona, she was determined 
to develop a better instrument for teaching 
and assessing both the content and the 
process of medical interviewing— an instru- 
ment that would be based on behaviors, 
not abstract ideas, so that it could also be 
used for giving feedback to the students. 
The Arizona Clinical Interview Rating 
Scale (ACIR)— or "Arizona Scale" as it 
became known— was the first behaviorally- 
anchored Likert scale to assess medical 
interviewing skills.-^ 

The histories Stillman taught her 
simulated mothers to give were compila- 
tions of the stories of several children, 
often including their own, laid out in the 
format of a checklist. She also taught the 
mothers how to use the checklist, to record 
whether or not a given item was asked, and 
then to give feedback to the students on 
their interviewing skills. 

I wasn't doing anything fancy with simulation. 
It was strictly common pediatric problems and, 
by that time, well accepted interviewing skills. 
The mothers would play the role of the patient 
and then, at the end, they'd go over the 
content checklist and the process checklist. In 
the beginning, I used to videotape everything. 
But [the mothers] got so good at remembering 
specifics when they gave feedback that I 
stopped videotaping.-'' 

Then, in the mid-1970s, Stillman was 
asked to run the physical diagnosis course. 
She was advised by her colleagues not to 
accept the position because she was too 
young to take what was considered to be "a 
dead-end job." But Stillman was drawn to 
education, and she saw this as an opportu- 
nity to expand the work she had started in 
the pediatric clerkship. She was curious to 
see if she could develop something for the 
physical exam that was similar to the inter- 
viewing scale. Stillman felt the problem 
with existing physical exam checklists was 
that they were too vague and mostly in 
outline form: 

Examine the Heart, Examine the Eyes, 
Examine the Abdomen. They weren't teaching 
tools. By reading the checklists, you couldn't 
tell what behavior was expected. So I devel- 
oped a physical exam checklist, with family 
practitioners and internists, [that] had over 200 
items on it. It broke down each component of 
the physical exam, so when it said "Examine 
the Eyes," there were twenty things you had to 
do when you examined the eye.^^ 

Stillman found a healthy man and a 
healthy woman, the first "patient instruc- 
tors," whom she taught to use this check- 
list.^^ Not only did they know what it felt 
like when each maneuver was done 
correctly, but they knew how to teach the 
student to do it properly. As she explained, 
"[I]f you weren't reaching up high enough 

12 Standardized Patients in Medical Education 

in the axilla when you were palpating the 
axillary lymph nodes, they could teach you 
how to do that. They knew nothing about 
medicine. They were strictly process 
people."-^ Stillman's patient instructors 
were not simulating a real patient, they were 
using their own normal bodies to teach the 
medical students how to do a complete, 
accurate physical examination using a 
detailed checklist designed by clinicians. 

The only other physician doing anything 
of similar import, at that time, was the 
obstetrician/ gynecologist Robert 

Kietzschmar, at the University of Iowa. In 
1968, inspired by Barrows's early work with 
simulated patients, he developed the first 
"gynecology teaching associates" (GTAs). 
The GTAs, using their own bodies, were 
trained to teach students and give them 
feedback on how to do a proper pelvic 
exam. 2^ In the beginning, the identity of 
the GTAs, then known as "professional 
patients," was obscured by covering the 
women's faces. 

The patient's responsibility was to note the 
various motions and sensations of the physi- 
cian's examination and compare each student's 
performance against these criteria. She there- 
fore gave minimal feedback to the student on 
his technique. . . . The simulated patient 
concept, in this rudimentary form, succeeded 
in providing a conducive environment for 
instruction with a relaxed, live model, but it 
did little to enhance communication between 
student and patient or reliably evaluate a 
student's technical performance.**" 

By 1972, Kretzschmar had greatly 
expanded the role of the GTA. No longer 
were the patients' identities masked. The 
GTA had been given increased responsibil- 
ities, including teaching the unique 
communication skills that go along with 
the practical skills of a quality pelvic 
examination. Kretzschmar saw that integra- 

Paula Stillmari with her youngest patient educator, 
Alexandra Roberts, at the University of Arizona School 
of Medicine 

tion of the two skills was primary. In the 
open climate of the 1970s, his approach to 
the learning of this sensitive examination 
was readily received by the Ob/Gyn 
profession, by the women who participated 
in the program, and by those who 
benefitted from it. Within a few years, a 
number of medical schools started their 
own GTA programs, many of which are 
still in existence today. 

Stillman eventually invited Kretzschmar 
to the University of Arizona to speak about 
his work. In the meantime, with her 
normal physical-exam patient instructors 
in place in her second-year physical 
diagnosis course, Stillman knew she "could 
guarantee that before each student entered 
his third-year clerkship[s], he could go 
through a systematic physical exam."^' She 
felt confident in the process, until one day 
she observed a senior medical student who 
was examining a patient with severe 

I said to him, "What do you hear?" And he 
said, "I don't hear anything. The lungs sound 
normal." And I said, "Has anybody ever 
checked out your findings?" And he said, "No, 
but I listened all over the chest and I 
percussed." And I realized that I never checked 

Peggy Wallace 13 

that the students could differentiate normal 
from abnormal.^- 

This awareness inspired Stillman to 
search for patient instructors who had 
actual physical findings: 

Tucson [had] a wonderful population of 
patients with chronic diseases who were very 
smart and who had made enough money that 
they could retire early and really didn't have 
much to do. I found a man with terrible 
bronchiectasis who had been an engineer for 
an astronomical observatory who couldn't 
work anymore. I found a woman with severe 
aortic stenosis. I found another one with severe 
asthma. I found a woman with severe 
arthritis. ^-^ 

These four were the original patients 
with chronic findings. Stillman trained 
these patients to use her normal physical- 
exam process checklist along with a new 
content checklist that she designed to take 
into account the specifics of the actual 
findings of each patient instructor. She 
then taught the patients both how to 
examine themselves, and how to teach the 
students to detect the abnormality on their 
own bodies.'''* For instance, in teaching the 
student, the patient would place the stetho- 
scope properly on her own body until she 
could hear her own abnormal finding, 
then she would hold the diaphragm in 
place while the student listened through 
her stethoscope. Stillman explained that 
the patient would then describe in detail 
the features the student should be listening 
for: "This is a systolic murmur. First, you 
[will] hear SI and then you [will] hear the 
murmur starting after Sl."^^ 

Stillman used this method in lieu of 
simulation "because I had this extraordi- 
nary cadre of patients. By the time I left 
Arizona, I must have had seventy-five 
patients who had chronic stable findings 

[in] every organ system. "^^ In working with 
these men and women and honoring them 
as co-educators, Stillman commanded such 
respect and dedication to the goals of her 
teaching program that, even after she left 
to take a position at the University of 
Massachusetts, many of those same 
patients continue years later to hold her 
inspiration in their present-day work with 
students at the University of Arizona.^ '^ 

The next development for Stillman was 
an integration of the split: "I realized that I 
was doing the history and I was doing the 
physical and I had never really put it 
together."^^ So she began working with 
some of the patients with chronic stable 
findings, simplifying their complicated 
histories, and putting together for them 
both history and physical in lengthy 45- 
minute encounters to use with her residents. 

About this same time, in the mid-to-late 
70s, Stillman began to invite people who 
she felt were doing "interesting work" in 
medical education to present their studies 
in Arizona. Among them were 
Kretzschmar, Abrahamson, and Barrows, 
all of whom had developed a body of 
sophisticated simulations. As usual. 
Barrows brought a standardized patient to 
help demonstrate his simulation 
techniques. The patient enacted several 
cases demonstrating what most people 
would assume to be impossible symptoms 
to simulate, including a pneumothorax and 
a comatose patient with Cheyne-Stokes 
breathing who, upon stimulation, throws a 
decerebrate fit and stops breathing. 
Stillman was impressed. "I had never seen 
this before," she said. "I thought this was 
the most extraordinary thing I had ever 
seen. I wasn't doing work with simulation 
because my patients had real findings. "^^ 

That simulated patient with the impres- 
sive simulated findings was Robyn M. 

14 Standardized Patients in Medical Education 

Tamblyn, a nurse who was working wilh 
Barrows at McMaster. Tamblyn, another 
enduring thread in the history of standard- 
ized patients, went on to write her doctoral 
dissertation on the emerging standardized 
patient methodology.^*^ She continues to 
work in the field of medical education and 
has made significant contributions to the 
standardized patient literature. 

In 1982, when Stillman became 
Associate Dean for Curriculum at the 
University of Massachusetts, she realized 
she couldn't replicate the University of 
Arizona program exactly as it was. "1 
started to do work with simulation [in 
Massachusetts] because ... I couldn't find 
that incredible pool of brilliant patients 
with chronic stable disease."^' Stillman has 
written, published, and presented on her 
work from the beginning, but the truly 
significant contributions she has made to 
this field were about to come, starting with 
the work she did in New England in the 

The names of Howard Barrows and 
Paula Stillman appear like interweaving 
threads throughout the history of 
standardized patients. Where Barrows 
started using simulation in demonstrations 
and for summative evaluation, Stillman 
began her work using patient instructors 
for teaching and formative assessment. 
Though both started with checklists, up to 
the early 1980s, their two approaches to 
education were different. Barrows's explo- 
ration of the principle "learn-medicine-as- 
you-will-practice-it" led him to incorporate 
the less tangible elements of the clinical 
reasoning process into his version of 
problem-based learning. The veritable 
encounters he designed for students with 
simulated patients integrated cognitive 
learning and practical experience into the 
"messiness" of human interaction. 

Stillman's exploration was based on 
improving traditional educational 
methods. She focused on concrete behav- 
iors, thoroughness in the basic skills of 
interviewing, medical history-taking and 
physical exam to assure that students were 
prepared for their required clinical 
rotations. However, for both Barrows and 
Stillman, the simulated patient became the 
vehicle by which they were able to investi- 
gate their clinical education insights, 
realize the significant accomplishments of 
those explorations, and, in so doing, hold 
the threads until the climate was conducive 
for others to weave in their own investiga- 

The 1980s and 1990s 

In 1981, Barrows left McMaster to become 
Associate Dean for Education at Southern 
Illinois University (SIU) School of 
Medicine. It was there that his emphasis in 
using the simulated patient changed from 
"a personal tool for a neurologist with 
teaching and assessment responsibilities to 
a tool for the development of medical 
education programs in the curriculum. "^'- 
In June 1984, on the anniversary of the 
tenth commencement of the SIU School of 
Medicine, Barrows and a number of others 
"felt that this milestone should be 
celebrated in conjunction with another 
event affirming the school's mission. . . . 
The increasing national concern about 
curricular abuses suggested that a confer- 
ence focusing on curricular reform issues 
would be appropriate."^'' 

This invitational conference, "How to 
Begin Reforming the Medical 
Curriculum," co-sponsored by the Josiah 
Macy, Jr. Foundation and the SIU School 
of Medicine, ignited the adoption of 
standardized patients, exploding their use 
in medical schools across the country. Up 

Peggy Wallace 15 

to that point, simulated patients were seen, 
by all but a few fervent advocates, as not 
much more than an interesting educational 
device. This conference provided the 
impetus to begin scrutinizing the efficacy 
of evaluating clinical competence by using 
standardized patients in multiple-station, 
performance-based assessments. The 
standardized patient examination was 
beginning to be seen not only as a valuable 
tool for individual student assessment, but, 
more potently, as the means for instigating 
curricular change in medical education. 

In an effort to convince deans and 
associate deans of the usefulness of 
standardized patients, the Macy Foun- 
dation supported a number of follow-up 
experiential, standardized patient demon- 
strations. The first of these, "Newer 
Approaches to the Assessment of Clinical 
Performance," occurred in October 1984, 
when the attendees of that first invitational 
conference, which had taken place four 
months earlier, were invited back to SIU 
for a hands-on, multiple-station standard- 
ized patient demonstration that took place 
in the first fully-equipped, dedicated 
simulated clinic in the country. Designed 
by Barrows, this Professional Development 
Laboratory, as he called it, became the 
model for other schools as standardized 
patient programs grew and the need for 
dedicated clinic space became a reality. 

No other demonstrations were funded 
by the Macy Foundation until just before 
Thomas H. Meikle became president. 
Meikle, himself a former dean of the 
Cornell University School of Medicine, 
knew that if this new standardized patient 
methodology were to have a chance of 
getting a toehold in medical schools, it 
would be the deans of the schools who 
would need to be convinced of its value. 
Meikle put together a blue ribbon com- 

mittee chaired by David Rogers, to study 
clinical medical education, particularly 
performance-based assessment. One of the 
six recommendations for medical school 
faculties that came out of that conference 
was to "require medical students to pass 
comprehensive performance-based clinical 
examinations" before graduating.^'* 
Following this conference, his vision of the 
importance of clinical skills assessment 
reinforced, Meikle "began a process 
basically to educate deans and to educate 
my board. "^^ The 1960s education mantra 
"Evaluation drives the curriculum" guided 
Meikle's efforts. He, along with many 
other medical educators, knew that if one 
wanted to make a difference in the way 
medicine was taught, one needed to 
change the way it was evaluated. Meikle 
has consistently held the vision of direct 
observation of clinical skills as a critical 
element in the education of medical 
students, even when his Board of 
Directors, which included a number of 
physicians, expressed uncertainty about 
the efficacy of performance-based assess- 

The next Macy support was received by 
Abrahamson at USC. In 1987 at Asilomar, 
California, he led the effort to win the 
support of medical school deans with 
another multiple-station, hands-on demon- 
stration using standardized patient cases 
from SIU. This time the demonstration 
was solely for deans of the western 
regional medical schools. Following the 
success at Asilomar, Barrows modeled 
similar demonstrations for deans at 
medical schools in the other three regions 
of the country over the next several years. 
Out of these five Macy-funded participa- 
tory demonstrations, involving ninety-one 
medical schools, came enthusiastic interest 
in standardized patient examinations as a 

16 Standardized Patients in Medical Education 

potential, viable solution to the evaluation 
of medical students' clinical competency. It 
came from the majority of medical schools 
in the United States; and it came from the 
highest academic level, from medical 
school deans, whose written responses to 
these demonstrations were sent to the 
Macy Foundation as letters requesting 
financial support to explore performance- 
based assessment at their own institutions. 

Mcikle wanted to respond without delay 
to the deans' interest, but he was still 
dealing with some members on his own 
board who were "very unconvinced" 
because they felt that medical students 
would reject these "surrogates who are 
pretending." He contacted Mt. Sinai, a 
medical school in close physical proximity 
to the Macy Foundation in New York City, 
to see if the dean would be interested in 
starting a standardized patient program. 
Meikle's idea was to provide a firsthand 
experience for his board of trustees, 
similar to the demonstrations that had 
proven to be so convincing to the medical 
school deans. By 1990, as a result of a 
burgeoning standardized patient program, 
the Morchand Center for Clinical 
Assessment was built at Mt. Sinai. Meikle 
then persuaded the trustees of the Macy 
Foundation to hold one of their meetings 
at the new center. "That," he recalled, "was 
the way I convinced, particularly the physi- 
cians and educators on the Macy board, to 
set up the consortia. "^"^ 

In 1991 and 1992, the Macy Foundation 
awarded grants to support six consortia 
with the expressed purpose of building 
cooperation among schools as each consor- 
tium developed a capability for designing 
and utilizing a standardized patient Clinical 
Practice Examination (CPX) for their 
students. The Macy Foundation also had 
the foresight to establish an umbrella 

Institutions Participating in Consortia, 1996 

Consortium contact is italicized 
Educational impact of Macy Project Affiliated Consortia (Ef^PAC) 
coordinated by Souttiern Illinois University School of Medicine 

Josiah Macy, Jr. Foundation-Sponsored Consortia (28 schools) 
Gulf Coast Regional Consortium for Assessment of Performance: 

University of Texas at Galveston, University of Texas at Houston, Baylor 

Metropolitan New York Center for Clinical Competence: Mount Sinai 
School of Medicine, New York Medical College, Albert Einstein College 
of Medicine, Cornell University, New York University, State University of 
New York (SUNY) at Brooklyn, SUNY at Stonybrook, Columbia College 
of Physicians and Surgeons 

North Carolina Medical Schools Consortium: University of North 
Carolina, Bowman Gray, Duke University, East Carolina University 

Northwest Consortium for Assessment of Clinical Performance: 

University of Washington, University of Nevada, Oregon Health 
Sciences University, University of Colorado 

Southern California Consortium for Assessment of Clinical 
Competency: University of Southern California; University of California, 

Irvine; University of California, Los Angeles; University of California, San 

Diego; Loma Linda University 

Upstate New York Clinical Competency Center: Albany Medical 
College, SUNY at Buffalo, SUNY Health Sciences Center at Syracuse, 
University of the State of New York Regents College Nursing Program 

Independent Consortia (13 schools) 

Chicago Clinical Skills Consortium: University of Illinois at Chicago, 
Finch University of Health Sciences/Chicago Medical School, Loyola 
University, Northwestern University, University of Chicago, Rush Medical 

New England Consortium: University of Massachusetts, Boston 
University, Harvard University, Tufts University, Brown University, 
Dartmouth University, University of Connecticut 

organization which was responsible for 
regularly bringing together the leaders 
from the six consortia in order to share 
information and to ensure that the educa- 
tional impact of consortia activities would 
be measured and documented. That 
organization, EMPAC (Educational Impact 
of Macy Project Affiliated Consortia), was 
established at the SIU School of Medicine 
under the direction of Howard Barrows. 
Along with the twenty-eight medical 

Peggy Wallace 1 7 

schools involved in the Macy Consortia,''^ 
two independent consortia were formed: 
the New England Consortium by Stillman 
in the IGSOs"*^ and, most recently, the 
Chicago Clinical Skills Consortium by the 
psychometrician and medical educator 
Reed G. Williams. Schools in these eight 
consortia, along with several other 
individual schools, represent almost one 
third of American medical schools that 
have been or are currently engaged in the 
development of a required performance- 
based clinical assessment of their 
students. ^'^ 

Integrating the Wisdom of the Staff 

The Association of American Medical 
Colleges (AAMC) and the American 
Medical Association (AMA) were responsi- 
ble for metaphorically digging the post- 
hole for the rod of the caduceus through 
their interest and their activities in sup- 
porting the firm establishment of standard- 
ized patient methodology into medical 
school curricula. First came the criticisms 
and recommendations for American med- 
ical education in the 1984 report Physicians 
for the Twenty-First Century: Report of the 
Panel on the General Professional Education of 
the Physician and College Preparation for 
Medicine (commonly known as the GPEP 
Report). 5° Then, the AMA Liaison 
Committee on Medical Education (LCME) 
formally incorporated into its accredita- 
tion standards the directive requiring that 
each medical school "develop a system of 
assessment which assures that students 
have acquired and can demonstrate on 
direct observation the core clinical skills 
and behaviors needed in subsequent med- 
ical training."^^ Finally, two reports were 
published by the AAMC, which sponsored 
the 1992 "Consensus Conference on the 
Use of Standardized Patients in the 

Teaching and Evaluation of Clinical 
Skills. "^2 As a consequence, the interest in 
standardized patients as a means of assess- 
ing clinical competency grew, not just in 
the rarified air of the ivory tower academic 
or the medical education theoretician and 
researcher, but, more importantly, at the 
grassroots level of individual medical 
schools. A 1993 AAMC survey sent to all 
142 North American medical schools 
requested information on use of standard- 
ized patients. Of the 138 schools respond- 
ing, 111 reported using SPs for both teach- 
ing and evaluation and thirty-nine of those 
schools were using standardized patients in 
a comprehensive examination to assess 
clinical skills before graduation. ^^ 

Weaving the Fabric: Standardized Patients 
and Performance Assessment 

The major focus of medical education 
research involving standardized patients 
from 1984 to the present has been perfor- 
mance assessment. It is the emphasis on 
performance assessment, in its many varia- 
tions, that has given face validity to the use 
of standardized patients and encouraged 
the wide spread acceptance of this educa- 
tional innovation. Because of the emphasis 
on evaluation during this period, there has 
been a shift away from all previously used 
terminology, in preference for the almost 
exclusive use of the expression standardized 
patient. Though one often still does hear 
the term simulated patient, it is primarily 
used to refer to the SP as a more generic 
teaching and learning tool, rather than 
exclusively as one for evaluation. 

It is perhaps also valuable to clarify the 
differences between the two types of 
performance-based assessments: the 
Objective Structured Clinical Examination 
(OSCE) and the CPX. The OSCE was 
introduced in Scotland in the mid-1970s by 

18 Standardized Patients in Medical Education 

Ronald Harden of the University of 
Dundee. ^^ In the intervening years, the 
OSCE has been refined by Harden's 
Scottish colleague Ian Hart, currently on 
the Faculty of Medicine at the University 
of Ottawa. Hart has been responsible for 
the introduction of standardized patients 
and the OSCE into many specialty exami- 
nations of the Royal College of Canada. 

The OSCE tests specifically defined 
single skills. OSCE station instructions 
might direct the student to perform a chest 
exam, take a blood pressure on a real 
patient, take a substance abuse history 
from a standardized patient, start an IV on 
a plastic model arm, read an X-ray, or 
interpret lab results. In Barrows's words, 
the OSCE assesses the skills of the exami- 
nees by "taking a biopsy" of their clinical 
ability. The OSCE generally relies heavily 
on real patients. It may or may not incor- 
porate standardized patients. Station 
length is usually short (four to ten 
minutes), depending on the complexity of 
the individual tasks comprising the exam. 
And in an OSCE, it is most often faculty 
who observe and rate the student's perfor- 

On the other hand, the CPX is designed 
to give students the opportunity to 
perform with a standardized patient as if 
they were practicing clinicians in an actual 
encounter. Students must rely on their own 
clinical judgment, responding in whatever 
way seems appropriate based on the 
patient complaint. The CPX is designed to 
assess the whole clinical process including 
history-taking, appropriate focused 
physical examination, patient education, 
and interpersonal skills. CPX stations are 
generally a minimum of fifteen to twenty 
minutes in length. The cases are portrayed 
by carefully trained standardized patients. 
And in a CPX, it is the standardized 

patient who records the examinee's 
behavior on a checklist after each 
encounter. Barrows summarized the differ- 
ences succinctly: 

This [CPX] format focuses on the student's 
abihty to use all clinical skills and to orches- 
trate them in an appropriate way with appro- 
priate priorities depending upon the problem 
that was presented. 

The OSCE can determine whether a student 
is capable of canying out a particular skill, but 
does not determine whether the student will 
use that skill with an appropriate problem. ^^ 

Since there has been a tendency to call 
all multiple-station, performance-based 
exams OSCEs, Meikle convinced Barrows 
of the importance of coming up with a 
name that distinguished the OSCE from 
the type of clinical exam that Barrows was 
engaged in at SIU. It was at Meikle's 
urging that Barrows searched for a name: 
"When you hear it you know what it is. It's 
a Clinical Practice Examination. You're 
examining the student in a clinical practice 
situation— complete interviews with a series 
of patients, like in a practice. "^*^ 

After Barrows's first multiple-station 
standardized patient demonstration at SIU 
in October 1984, the ten invited deans 
empowered another of the conference 
participants, Stephen Abrahamson, to 
convene a committee to further the devel- 
opment and medical school use, of this 
type of performance assessment, and to 
find funding to support that effort. This 
task force, known as Project Mousetrap, 
was ahead of its time in 1985. 

Two activities were explored by Project 
Mousetrap: "The Snake Oil Project"^^— 
"traveling road shows to sell schools on the 
use of standardized patients in the assess- 
ment of student clinical performance"— 
and "Building a Better Mousetrap"— the 

Peggy Wallace 1 9 

Number of Articles Published on 


Patients, 1966-1996 









establishment of cooperation among 
several schools to determine graduation 
objectives, to design examination 
blueprints, and to develop quality cases, 
psychometrically sound checklists, and 
standardized patient training protocols 
that would assure test reliability. According 
to Abrahamson, "The Task Force agreed 
that it was really interested in the Better 
Mousetrap and turned its attention to the 
development of this project. "^^ Ironically, 
though no funding was found before the 
group disbanded, a few years later both of 
the concerns of Project Mousetrap became 
the missions of a combination of other 
organizations: the Macy Foundation 
through its support of the "travelling road 
shows" for deans and through the estab- 
lishment of CPX-based consortia; and the 
National Board of Medical Examiners 
through its ongoing valiant efforts to estab- 
lish a performance-based, clinical-compe- 
tency examination as part of Step II of the 
United States Medical Licensure 
Examination (USMLE). 

Besides Abrahamson, Barrows, and 
Stillman, and representation from the 
AAMC, the committee consisted of a 
number of psychometricians: Geoffrey 
Norman of the Department of Clinical 

Epidemiology and Biostatistics at 
McMaster; David B. Swanson of the 
American Board of Internal Medicine 
(ABIM); Dax Taylor, Vice President for 
Test Development at the National Board of 
Medical Examiners (NBME); and Reed 
Williams of the Department of Medical 
Education at SIU. The psychometric 
aspects of performance-based examina- 
tions were already becoming the principal 
focus of research. The major measurement 
concerns were the usual ones: reliability 
and reproducibility of test results, validity, 
feasibility, scoring, and reporting. 
However, the unique demands of this new 
test modality— using multiple standardized 
patients who perform the same case within 
a site or across sites; multiple standardized 
patient raters using the same checklist; 
number and length of cases needed for a 
reliable measure; criteria to determine 
"clinical competence"; and many more 
such concerns— challenged the creative 
thinking of psychometricians, most of 
whom had previously worked in the more 
cognitively-pure area of multiple-choice 

By the end of 1985, it was clear that the 
climate among the foundations that tradi- 
tionally fund medical education projects 
was not quite ripe for the ambitious 
consortial nature of Project Mousetrap. 
However, under Abrahamson's leadership, 
Project Mousetrap did inspire a number of 
important individual efforts from among 
members of the task force that, in turn, 
spawned research by other investigators 
beyond the group, finally galvanizing 
critical financial support from some of the 
very organizations who failed to see the 
landmark nature of what the Better 
Mousetrap group had attempted to accom- 
plish. These generative research studies 
have contributed significantly to the 

20 Standardized Patients in Medical Education 

improvement of CPX psychometrics and to 
the dissemination of the chnical practice 
examination across a broad range of 
medical schools. 

A decade after Barrows and Williams 
mounted the first clinical practice exami- 
nation at SIU in 1985,^^ two key review 
articles finally gave legitimacy to large- 
scale standardized patient-based examina- 
tions: "Assessment of Clinical Skills with 
Standardized Patients: State of the Art" by 
Cees van der Vleuten and David B. 
Swanson (a review of psychometric 
research)''*^ and "Use of Standardized 
Patients in Clinical Assessments: Recent 
Developments and Measurement Findings" 
by Nu Viet Vu and Barrows.*^' With the 
publication of these reviews focusing on 
the psychometric aspects of large-scale 
clinical assessments using standardized 
patients, it was no longer necessary to 
justify the essential reliability, validity, and 
feasibility of these types of tests. One no 
longer had to apologize to skeptics of 
standardized patient-based examinations, 
one merely had to refer to these reviews. 

During the same time, Paula Stillman 
and David Swanson teamed up, working 
together for about six years with funding 
from the American Board of Internal 
Medicine, which was searching for a better 
performance-based method of assessment 
for certification than its Clinical Evaluation 
Exercise (CEX), which involved a single 
faculty observation of a resident with a 
patient during the first postgraduate year of 
training. They completed the first-of-its- 
kind, multi-institutional study of the clinical 
competence of internal medicine residents 
using standardized patients,^- and eventu- 
ally established a CPX-type examination for 
fourth-year students at the University of 
Massachusetts and several other medical 
schools in the New England area.^^ 

Simultaneous with these efforts came 
the National Board of Medical Examiners' 
Standardized Patient Project exploring a 
"high stakes" clinical assessment compo- 
nent for licensure, the Macy Foundation 
support of medical school consortia, and 
the Educational Council for Foreign 
Medical Graduates' (ECFMG) pilot project 
to assess the clinical competence of gradu- 
ates of medical schools outside of North 
America who were in U.S. residency 
programs. "^^ All of these efforts were 
aimed at finding a viable method to 
accurately assess clinical competence, the 
consequence of which was the further 
development, refinement, and ultimate 
acceptance of standardized patients as that 

One of the other threads in this narra- 
tive is Daniel J. Klass, the director of the 
NBME Standardized Patient Project. His 
coming to the National Board of Medical 
Examiners interweaves with a number of 
other threads in the history of the growing 
use of standardized patients. In the early 
1980s, Klass was the Associate Dean for 
Medical Education at the University of 
Manitoba. He, like everyone else who is 
required to write "dean's letters" of refer- 
ence for students embarking on post- 
graduate work, was dependent upon 
written evaluations from faculty who often 
disagreed about the quality of the student 
in question. "I started looking into the 
literature on clinical evaluation and found 
very little to go on," he said. "The litera- 
ture was depressing. Whatever you saw said 
exactly the same thing, clinical evaluation 
was not very good."*^^ 

Around the same time, a nurse by the 
name of Robyn Tamblyn moved to 
Manitoba. According to Klass: "She came 
into my office wondering if there was any 
work that she could get in the Department 

Peggy Wallace 21 

of Medical Education and I didn't know 
who she was. I'd never heard of Robyn 
Tamblyn. I'd never heard of Howard 
Barrows. I found out pretty quickly."^^ 

Robyn Tamblyn, of course, had been 
one of the first simulated patients trained 
by Barrows at McMaster. Her introduction 
to the world of standardized patients came 
while she was working with him as part of 
a neurological patient care team. When 
one of Barrows's simulated patients 
became too pregnant to perform at a 
meeting of the Association of Neurological 
Professors, Barrows convinced Tamblyn, 
who had never heard about the technique 
before, to become an SP. According to 
Barrows: "She became one of the best SPs 
I ever worked with and in a very short 
while became a trainer of SPs and set up 
the first organized SP program at Mac. 
That means that when she presented 
herself to Klass, it was not just as an SP, 
but as an SP trainer and program 

Tamblyn encouraged Klass to think 
about initiating a standardized patient 
program and introduced him to Barrows at 
the next AAMC meeting. Klass visited SIU 
shortly thereafter, went through Barrows's 
classic hands-on experience with a 
standardized patient, and, promptly 
decided to do a two-site CPX project 
together with Barrows. "Out of the blue, 
[we] created a standardized patient 
program that piggy-backed onto Howard's, 
in that we started by just saying, 'We're 
going to do an exam with SIU.'"^^ 

SIU initiated the project by supplying 
the cases, the faculty demonstrations, and 
the expertise. Within a few months, Klass 
and Tamblyn had mounted an examination 
for all the students at the University of 
Manitoba using standardized patients who 
had been trained locally. Out of the two- 

school examination experience, between 
1985 and 1987, came a number of inter- 
esting findings regarding portability of 
cases and standardization of SP perfor- 
mances across sites. ^^ 

Klass's early connection with Barrows 
was significant in influencing the work he 
was about to begin at the National Board. 
Barrows, he said, "did with us what we 
have since tried to model with many other 
schools. The best way to learn how to do 
standardized patients is to do it along side 
of someone who has already done it 
before. It's [the] apprenticeship system. "'^'^ 

The NBME has never worked in isola- 
tion. It has always seen the success of its 
licensing mission dependent upon collabo- 
ration, formal or informal, with its support 
coming from the State Federation of 
Medical Boards, the medical schools, and 
their faculty. This underpinning continues 
to guide the philosophy of the 
Standardized Patient Project in its work 
with medical schools, as well as with other 
organizations exploring the same territory. 

From the beginning of his presidency at 
Macy, Meikle stayed in conversation with 
the NBME, whose own issues helped him 
define the next steps for the Macy 
Foundation. "Basically what I thought they 
[NBME] were concerned about was how 
they were going to test 16,000 students. 
And I thought this was a legitimate issue. 
So it seemed to me, the question 
was:'What could schools do with [a] 
relatively minimal amount of money? And 
what could they do by sharing^ And that 
was the consortial concept. "^^ 

As it has evolved, the success of the 
Standardized Patient Project has 
depended, in some measure, on the very 
existence of the Macy consortia. Over the 
last five years, the twenty-eight Macy 
schools have provided the National Board 

22 Standardized Patients in Medical Education 

with a majority of its sites for piloting 
everything from logistics, to trainer educa- 
tion, to case performance. The Macy 
Foundation has begun to establish grass- 
roots acceptance of standardized patient 
examinations at the medical school level. 
In fact, the dependence of faculty on the 
data from such examinations, which have 
been in place for several years, has laid the 
groundwork so necessary for the NBME to 
function. In Klass's words: "A standardized 
process that can be used as part of licen- 
sure across the whole country will only 
work if standardized patients become part 
of the culture of medical schools using 
standardized patients for their own 
purposes, not to meet the needs of licen- 
sure, but for their own evaluative 
purposes, for their own teaching 

There is an ongoing struggle to integrate 
the focus of the medical schools— which is 
to educate its students to the highest 
standards of excellence— and the concern 
of the National Board to establish 
"minimal national standards of clinical 
competence" for licensure. But, in many 
ways, there is a recognition by both parties 
that each needs the other. In order to 
maintain the existence of the standardized 
patient teaching and assessment programs 
at the medical school level, many schools 
need the pressure of the NBME interest in 
the clinical practice examination. This is 
particularly important in the budgetary 
atmosphere of the 1990s, when what 
happens in medical education is often 
defined by "fiscal exigency." In such a 
climate, no matter how powerful the data, 
an innovation that is just becoming estab- 
lished can easily be cut from the medical 
school budget. On the other hand, the 
NBME needs the continuing fertile ground 
of grassroots, standardized patient 

programs because it is the medical schools 
that likely will provide the professional 
sites where the clinical competency licen- 
sure examination will be delivered when it 
is ready. These mutual needs are bringing 
integration to traditionally competing 
forces. It is the wisdom of the serpents— the 
essence of the caduccus. 

Separate but interwoven with the NBME 
Standardized Patient Project is a similar 
effort by the Educational Council for 
Foreign Medical Graduates (ECFMG). 
Here, again, a number of threads have 
come together. Alton I. Sutnick, former 
dean of the Medical College of 
Pennsylvania (MCP), was one of the 
original deans invited to the Macy/SIU 
invitational conference and demonstration 
in 1984. Abrahamson remembered 
Sutnick's response, more than any one 
else's, to his first experiences with 
standardized patients at that demonstra- 
tion: "Each time he came out of a case, his 
eyes were as big as saucers because he 
could see the power of this thing. "^^ 
Sutnick's own remembrance of that experi- 
ence corroborated Abrahamson's: "Boy, 
was I impressed! I thought it would be 
something like a regular role playing, but it 
was so much more. I could really see what 
he [Barrows] was talking about so enthusi- 
astically. He had said: 'You'll never appre- 
ciate it until you experience it yourself . . . 
It was during that day that I saw that this 
really did have the potential for assess- 
ment, and that it ought to be promoted. "'^^ 

Within a short time, Sutnick invited 
Paula Stillman to speak with his faculty at 
MCP, found clinic space, and appointed 
the team that established the first standard- 
ized patient program in Philadelphia. 

A couple of years later, Robert 
Petersdorf, then president of the AAMC, 
invited Sutnick to sit with him in one of 

Peggy Wallace 23 

the two AAMC seats on the ECFMG board 
of trustees. ECFMG, whose mission is to 
certify foreign medical graduates for 
practice in the United States, was an 
organization with two attractions for 
Sutnick, working with internationally 
trained physicians and exploring the 
assessment possibilities of standardized 
patients. Sutnick remembered: 

The ECFMG board had already begun looking 
into how to test clinical skills with some studies 
[that had been] done in the mid-'80s.^^ These 
involved taking histories and doing physical 
examinations on real people. There were a lot 
of psychometric problems, so that the board 
wasn't ready to accept that direction. They 
appointed a new committee to review [that 
work] and decide what to do.^^ 

Because of his experience at MCP, 
Sutnick was asked to serve on that 
committee. Through a series of circum- 
stances, Sutnick recalled, "I found myself 
in the role of planning and making recom- 
mendations on what ECFMG should do." 
Within a short period of time, the new 
president of ECFMG asked Sutnick if he 
might be interested in being a candidate 
for vice president. Years before, Sutnick 
had enjoyed working collaboratively with 
basic scientists from other countries and 
had been interested in the concerns of 
foreign medical graduates since his work 
in the 1960s with the Philadelphia County 
Medical Society, where he provided "hospi- 
tality for foreign physicians, including 
foreign medical graduates who were taking 
residencies in Philadelphia." "Little did I 
know," he said, "that some 25 years in the 
future I would become vice president of 
ECFMG."" Sutnick left MCP to take this 
new position in 1989. 

As vice president, he became respon- 
sible for clinical skills assessment. The first 

thing he did was bring together a distin- 
guished group of educators who had been 
working with standardized patient-based 
performance assessment, including 
Howard Barrows, Paula Stillman, Ian Hart, 
and two psychometricians— Miriam 
Friedman, who had been consulting with 
ECFMG from the University of New 
Mexico, and John J. Norcini of the 
American Board of Internal Medicine. 

Because of the communication through 
medical education literature and the cross- 
fertilization taking place directly among 
the principal players, the various 
approaches to standardized patient-based 
performance assessment had essentially 
converged. According to Sutnick, the 
ECFMG clinical assessment committee 
"suggested that Stillman be the active 
person working with us. She had devel- 
oped a system, a process. She had a group 
of people who could contribute as collabo- 
rators. And that was crucial. "^'^ 

Stillman remembered how quickly the 
committee was able to get the pilot ready: 
"We set up four centers around the 
country. And I used cases that I knew. We 
trained patients at each of the sites. And it 
was done. . . . We put the exam together in 
a year."^^ So between 1990-1991, two pilot 
studies were mounted by the ECFMG using 
the same standardized patient cases that 
had been developed in New England for 
the fourth-year medical students' clinical 

A race to be the first to adopt a high- 
stakes, large-scale standardized patient 
clinical competency examination for licen- 
sure came to the forefront in the early 
1990s. The Medical Council of Canada 
(MCC), under the direction of Richard K. 
Reznick, was exploring the use of standard- 
ized patients for a national OSCE-type 
certification examination. Reznick's 

24 Standardized Patients in Medical Education 

interest in standardized patients grew 
during the year he spent working with 
Barrows at SIU while earning a master's 
degree in education. In 1993, under 
Reznick's direction, the MCC became the 
first organization to implement a national 
standardized patient-based performance 
assessment as a required part of the licen- 
sure examination.^^ In 1994, the ECFMG 
authorized the Clinical Skills Assessment 
as part of its certification process.^- And in 
1995, the NBME endorsed the use of a 
standardized patient examination as part 
of USMLE Step II with implementation to 
be within the next four to seven years. '^'^ 

Along with the growing use of standard- 
ized patients in North America, there has 
been a corresponding interest in standard- 
ized patients internationally. In 1985, Ian 
Hart and Ronald Harden organized the 
Ottawa Conference on Assessing Clinical 
Competence. This biannual forum has 
become "the largest regularly held interna- 
tional conference on medical education. "'^^ 
Over the years, standardized patients have 
gradually been incorporated into the 
curricula of other medical schools around 
the world through the important work of 
such individuals as Ronald Harden in 
Scotland, David Newble in Australia, Cees 
RM. van der Vleuten in The Netherlands, 
and Nu Viet Vu, who recently moved from 
SIU to Switzerland. Paula Stillman intro- 
duced the standardized patient to China; 
at the same time, the ECFMG has shown 
an interest in transporting the standard- 
ized patient methodology to a number of 
other countries with the dream of 
ultimately establishing global clinical 
standards. Towards that effort, the 
ECFMG, along with the World Health 
Organization, has assisted Israel, Spain, 
Russia, the Ukraine, and Brazil to mount 
standardized patient examinations that are 

designed for each of their country's 
needs. ^^ In little more than three decades, 
the use of the standardized patient in 
medical education has grown dramatically 
from its modest beginnings in California 
as a pedagogical novelty to the global 
phenomenon that it is today. 


Standardized patient methodology is no 
longer in question. Yet, in our rush to 
quantify and establish its efficacy, a new 
question emerges. Have we not forgotten 
how much potential there is for the stan- 
dardized patient in other areas— those 
wings on the caduceus? Assuredly, there is 
much left to be done in psychometrics, 
especially in the area of validity. Are we, in 
truth, assessing what we think we are— clini- 
cal competence? Is the design of the check- 
list, are all those details, really what we 
care about, or is there some other way to 
look at this? Now as much as ever, our cre- 
ative instincts are called for. 

As managed care is in ascendance, so 
might there be even more creative ways to 
use the standardized patient. The "patient 
instructor" might become a necessity 
rather than a luxury— and standardized 
patients might be even more extensively 
needed for clinical learning and self-assess- 
ment as the pool of teaching faculty 
dwindles. And what about the practicing 
physician, or the one who has lost his 
license to practice? Might not the standard- 
ized patient be able to support the physi- 
cian in new learning in the way of the 
Bedside Clinics or, in some way, make it 
possible for the physician-in-trouble to re- 


In looking back on any human endeavor, it 
is always interesting to see how diverse are 

Peggy Wallace 25 

the motivations that shape that history. 
Altruism and egotism entwined, create the 
path, inspire the wisdom that has shaped 
the movement towards the way we are now 
teaching and testing the chnical skills of 
the young people who will be our future 
physicians. This is the standardized 
patient, a single educational innovation 
that had as much chance, or more, of not- 
being as being. It is the thread that held 
the inspiration until all was ready for the 
weaving— the golden winged rod entwined 
with oppositional energy that symbolizes 
the integration around which so much else 
has been explored and discovered. May 
that golden rod, now firmly planted, con- 
tinue to inspire winged ideals in the midst 
of the inevitable conflict of opinions that 
will create the fertile soil for sustaining 
educational efforts as the search goes on 
for a better way to support the healers of 
today— and nurture those of tomorrow. 


1. Howard S. Barrows, interview by author, 
Springfield, 111., Feb. 18, 1996 (hereafter cited as 
Barrows interview). 

2. Ibid. 

3. "Hollywood Invades USC Medical School," LA 
Herald-Examiner, Sept. 27, 1965, A20. 

4. "Models Who Imitate Patients: Paradise for 
Medical Students," San Francisco Chronicle, Sept. 28, 
1965, 3. 

5. Howard S. Barrows and Stephen Abrahamson, 
"The Programmed Patient: A Technique for 
Appraising Student Performance in Clinical 
Neurology," /oMrraa/ of Medical Education 39 (1964): 

6. Barrows interview. 

7. Gregory J. Magarian and Dennis J. Mazur, 
"Evaluation of Students in Medicine Clerkships," 
Academic Medicine 65 (1990): 341-45. 

8. Barrows interview. 

9. Ronald Harden, Mary Stevenson, W. Wilson 

Downie, and G. M. Wilson, "Assessment of Clinical 
Competence Using Objective Structured 
Examination," British Medical Journal 1 (1975): 

10. Barrows interview. 

11. Howard S. Barrows, "An Overview of the Uses 
of Standardized Padents for Teaching and Evaluadng 
Clinical Skills," Academic Medicine 68 (1993): 446-51. 

12. Barrows interview. 

13. Ibid. 

14. Ibid. 

15. Ibid. 

16. Robin M. Tamblyn and Howard S. Barrows, 
"Bedside Clinics in Neurology: An Alternate Format 
for a One Day Course in Continuing Medical 
Education,"/AAlA 243 (1980): 1448-50. 

17. Barrows interview. 

18. Ibid. 

19. Ibid. 

20. Arthur S. Elstein, Lee S. Shulman, and Sarah 
A. Sprafka, Medical Problem Solving: An Analysis of 
Clinical Reasoning (Cambridge: Harvard University 
Press, 1978). 

21. Barrows interview. 

22. A. Burri, K. McCaughan, and Howard S. 
Barrows, "The Feasibility of Using the Simulated 
Padent as a Means to Evaluate Clinical Competence 
of Practicing Physicians in a Community," in 
Proceedings of the Fifteenth Annual Conference on 
Research in Medical Education (Washington, B.C.: 
Association of American Medical Colleges, 1976), 

23. Ray Heifer and Joseph Hess, "An 
Experimental Model for Making Objective 
Measurements of Interviewing Skills," yourna/ of 
Clinical Psychology 26 (1970): 327-31. 

24. Paula L. Stillman et al., "Construct Validation 
of the Arizona Clinical Interview Rating Scale," 
Educational and Psychological Measurement 37 (1977): 

25. Paula L. Stillman, interview by author, 
Philadelphia, Mar. 16, 1996 (hereafter cited as 
Sullman interview). 

26. Ibid. 

27. Paula L. Stillman, Darrell L. Sabers, and Doris 
L. Redfield, "The Use of Paraprofessionals to Teach 
Interviewing Skills," Pediatrics 57 (1976): 769-74. 

28. Sullman interview. 

29. Robert M. Kretzschmar, "Evolution of the 
Gynecology Teaching Associate: An Education 
Specialist," American Journal of Obstetrics and 
Gynecology 131 (1978): 367-73. 

30. Ibid., 368. 

31. Stillman interview. 

32. Ibid. 

26 Standardized Patients in Medical Education 

33. Ibid. 

34. Paul Rutala and Paula L. Stillman, The Non- 
Physician in Medical Education, ed. Stillman (Tucson: 
University of .\rizona, 1978), 26. 

35. Stillman inteniew. 

36. Ibid. 

37. M. Angevine, interview by author, Tuscon, July 
2, 1996. 

38. Stillman inter\iew. 

39. Ibid. 

40. Robin M. Tiunblyn, "The Use of Standardized 
Patients in the Evaluation of Cliniciil Competence: 
The Evaluation of Selected Measurement Properties" 
(Ph.D. diss., McGill University, 1989). 

41. Stillman interview. 

42. Barrows, "An Overview of the Uses of 
Standardized Patients." 447. 

43. Howard S. Banows and M.J. Peters, eds.. How 
to Begin Reforming the Medical Curriculum (Springfield: 
Southern Illinois University School of Medicine, 
1984). i. 

44. Barbara Gastel and David E. Rogers, eds.. 
Clinical Education and the Doctor of Tomorrow: 
Proceedings of the Josiah Macy, Jr. Foundation National 
Seminar on Medical Education, Adapting Clinical 
Medical Education to the Needs of Today and Tomorrow, 
Held June 15-18, 1988 (New York: New York 
Academy of Medicine, 1989), 112. 

45. Thomas H. Meikle, interview by author, 
Philadelphia, Apr. 1, 1996 (hereafter cited as Meikle 

46. Ibid. 

47. Linda J. Morrison and Howard S. Barrows, 
"Developing Consortia for Clinical Practice 
Examinations: The Macy Project," Teaching and 
Learning in Medicine 6 (1994): 23-27. 

48. Paula L. Stillman and David B. Swanson, 
"Ensuring the Clinical Competence of Medical 
School Graduates Through Standardized Patients," 
Archives of Internal Medicine 147 (1987): 1049-52; 
Paula L. Stillman et al., "Assessing Clinical Skills of 
Residents with Standardized Patients," Annals of 
Internal Medicine 105 (1986): 762-71. 

49. M. Browiiell Anderson, Paula L. Stillman, and 
Youde Wang, "Growing Use of Standaidized Patients 
in Teaching and Evaluation in Medical Education," 
Teaching and Learning in Medicine 6 (1994): 15-22. 

50. Steven Muller, Physicians for the Twenty-First 
Century: Report of the Panel on the General Professional 
Education of the Physician and College Preparation for 
Medicine (Washington, D.C.: Associauon of American 
Medical Colleges, 1984). 

51. Liaison Committee on Medical Education, 
Functions and Structure of a Medical School: 
Accreditation and the Liaison Committee on Medical 

Education: Standards for Accreditation of Medical 
Education Programs Leading to the M.D. Degree 
(Washington, DC: American Medical Association, 

52. M. Brownell Anderson and Donald G. 
Kassebaum, eds., "Proceedings of the AAMC's 
Consensus Conference on the Use of Standardized 
Patients in the Teaching and Evaluation of Clinical 
Skills," Academic Medicine 68 (1993): 437-83; Terrill 
A. Mast and M. Brownell Anderson, eds., "Special 
Section: Annex to the Proceedings of the AAMC 
Consensus Conference on the Use of Standardized 
Patients in the Teaching and Evaluation of Clinical 
Skills," Teaching and Learning in Medicine 6 (1994): 

53. Anderson, Stillman, and Wang, "Growing L'se 
of Standardized Patients," 15. 

54. Harden, Stevenson, Downie, and Wilson, 
"Assessment of Clinical Competence." 

55. Barrows, "Overview of the Uses of Stand- 
ardized Patients." 

56. Barrows interview. 

57. Stephen Abrahamson, Minutes, Project 
Mousetrap Task Force Meeting, May 23-24, 1985, 

58. Ibid. 

59. Reed G. Williams et al., "Direct, Standardized 
Assessment of Clinical Competence," Medical 
Education 21 (1987): 482-89; Nu Viet Vu et al., "Six 
Years of Comprehensive, Clinical, Performance- 
Based Assessment Using Standardized Patients at the 
Southern Illinois University School of Medicine," 
Academic Medicine 67 (1992): 43-50. 

60. Gees P. M. van der Vleuten and David B. 
Swanson, "Assessment of Clinical Skills with 
Standardized Patients: State of the Art," Teaching and 
Learning in Medicine 2 (1990): 58-76. 

61. Nu Viet Vu and Howard S. Barrows, "L'se of 
Standardized Patients in Clinical Assessment: Recent 
Developments and Measurement Findings," 
Educational Researcher 23 (1994): 23-30. 

62. Stillman et al., "Assessing Clinical Skills of 

63. Paula L. Stillinan, David B. Swanson, et al., 
"An Assessment of the Clinical Skills of Fourth- Year 
Students at Four New England Medical Schools," 
Academic Medicine 65 (1990): 320-26. 

64. .\lton I. Sutnick et al., "ECFMG Assessment of 
Clinical Competence of Graduates of Foreign 
Medical Schools: Educational Commission for 
Foreign Medical Graduates," /AMA 270 (1993): 
1041-45; Alton I. Sutnick, Paula L. Stillman, and 

John J. Norcini, "Pilot Study of the Use of the 
ECFMG Clinical Competence Assessment to Provide 
Profiles of Clinical Competencies of Graduates of 

Peggy Wallace 27 

Foreign Medical Schools for Residency Directors," 
Academic Medicine 69 (1994): 65-67. 

63. Daniel J. Klass, interview by author, 
Philadelphia, Mar. 14, 1996 (hereafter cited as Klass 

66. Ibid. 

67. Barrows interview. 

68. Klass interview. 

69. Daniel J. Klass et al., "Portabihty of a Multiple 
Station, Performance-Based Assessment of Clinical 
Competence," in Further Developments in Assessing 
Clinical Competence, ed. Ian Hart and Ronald Harden 
(Montreal: Can-Heal, 1987), 434-42; Robin Tamblyn 
et al., "How Standardized Are Standardized 
Patients?" in Proceedings of the 27th Research in Medical 
Education Conference (Washington, D.C.: Association 
of American Medical Colleges, 1988), 148-53; Robin 
M. Tamblyn et al., "The Accuracy of Standardized 
Patient Presentation," Medical Education 25 (1991): 

70. Klass interview. 

71. Meikle interview. 

72. Klass interview. 

73. Stephen Abrahamson, interview by author, 
Los Angeles, Mar. 11, 1996. 

74. Alton I. Sutnick, interview by author, 
Philadelphia, Mar. 14, 1996 (hereafter cited as 
Sutnick interview). 

75. Hadley L. Conn, Jr., "Assessing the Clinical 
Skills of Foreign Medical Graduates," /oMrna/ of 
Medical Education 61 (1986): 863-71; Hadley L. 
Conn, Jr., and Ronald P. Cody, "Results of the 
Second Clinical Skills Examination of the ECFMG," 
Academic Medicine 62 (1989): 448-53. 

76. Sutnick interview. 

77. Ibid. 

78. Ibid. 

79. Stillman interview. 

80. Sutnick et al., "ECFMG Assessment of Clinical 
Competence"; Sutnick, Stillman, and Norcini, "Pilot 

81. Richard K. Reznick et al., "An Objective 
Structured Clinical Examination for the Licentiate: 
Report of the Pilot Project of the Medical Council of 
Canada," Academic Medicine 67 (1992): 487-93; 
Richard K. Reznick et al., "Large-Scale High-Stakes 
Testing with an OSCE: Report from the Medical 
Council of Canada," Academic Medicine 71 (1996): 

82. Educational Council for Foreign Medical 
Graduates, "Clinical Skills Assessment: Brief History," 
Annual Report-Educational Commission for Foreign 
Medical Graduates (Philadelphia: Educational Com- 
mission for Foreign Medical Graduates, 1996), 16-17. 

83. "Highlights of the 1995 Annual Meeting of the 

Board," National Board Examiner 42, no. 2 (1995): 

84. "Ian R. Hart, MB, ChB Recipient of the 1996 
Hubbard Award," National Board Examiner 43, no. 2 
(1996): 1-3. 

85. Alton I. Sutnick, Miriam Friedman, and M. P. 
Wilson, "ECFMG International Ventures in Clinical 
Competence Assessment," in Proceedings of the Sixth 
Ottawa Conference on Medical Education, Toronto, 
Ontario, June 26-29, 1994, ed. Arthur I. Rothman and 
Robert Cohen (Toronto: University of Toronto 
Bookstore Custom Publishing, 1995), 311-12. 

PEGGY WALLACE is Associate Adjunct Professor of 
Medicine and Director of Curricular Resources and 
Evaluation at the University of California, San Diego 
School of Medicine, where she is responsible for the 
teaching and assessment of clinical skills in the 
undergraduate medical school curriculum. She held a 
faculty position at the University of Southern 
California (USC) in the Department of Medical 
Education from 1977-1995 and was responsible for 
the re-introduction of standardized patients into the 
USC medical school curriculum starting In the mid- 
1980s. From 1993-1996, she guided the activities of 
the Southern California Consortium for the 
Assessment of Clinical Competency sponsored by the 
Josiah Macy, Jr. Foundation. She has served as a 
consultant to the National Board of Medical 
Examiners on the Standardized Patient Project and to 
various managed care organizations on physician- 
patient communication. She has also conducted 
workshops nationally and internationally for the 
World Health Organization on instructional 
technology, the use of video in medicine, and 
standardized patient training and case development. 
She is currently working on a book entitled The Art 
and Practice of Using Standardized Patients in 
Clinical Education, which will be published in 1998 as 
part of the Springer Medical Education series. 


The author wishes to express her thanks to the people 
who agreed to share their insights with her about 
their roles in the living history of this educational 
innovation: Stephen Abrahamson, Howard S. 
Barrows, Daniel J. Klass.Thomas H. Meikle, Paula L. 
Stillman, and Alton I. Sutnick. The author also wishes 
to thank Karen German and Diane Richards for their 
support and guidance as this manuscript came into 

28 Standardized Patients in Medical Education 

Sim One— A Patient Simulator Ahead 
of Its Time 

Stephen Abrahamson 

Some Historical Notes 

Imagine, if you will, an artificial patient 
which might be used to train health-care 
personnel in clinical maneuvers which are 
potentially threatening to real patients and 
therefore difficult to teach. With today's 
technology, particularly state-of-the-art 
computers, it may not be that difficult to 
visualize such an apparatus: a simulated 
human being, capable of real-time, lifelike 
reactions to procedures done by the 
health-care trainee. 

Such a device was designed, produced, 
tested, and then used as long ago as 1967! 
Its inventors called it "Sim One" in 
optimistic anticipation of a long line of 
similar simulators to be used in teaching 
health-care students those clinical skills 
which involve potential threat to the 
patient on whom the skills must otherwise 
be learned. At the time of its "debut" on 
March 17, 1967, Sim One was quite lifelike 
in appearance, having a plastic skin which 
resembled that of a real (Caucasian) 
human being in color and texture. He (it 
was a male) had the configuration of a 
patient lying on an operating-room table 
with (1) his left arm extended and fitted 
with an intravenous portal ready for intra- 
venous injection; (2) his right arm fitted 
with blood-pressure cuff; and (3) his chest 
having a stethoscope taped over the 
approximate location of his heart. Sim 

One breathed, had a heart beat, temporal 
and carotid pulses (all synchronized), and 
blood pressure. He was able to open and 
close his mouth, blink his eyes, and 
respond to four intravenously administered 
drugs and two gases (oxygen and nitrous 
oxide) administered through mask or tube. 

The physiologic responses to what was 
done to Sim One were in real time and 
occurred automatically as part of the 
computerized program. It was possible to 
perform the entire maneuver of endotra- 
cheal intubation and administration of 
anesthesia in exactly the manner in which 
it was done in the operating room: admin- 
istration of oxygen through mask and bag, 
injection of sodium pentothal, injection of 
succinylcholine, insertion of an endotra- 
cheal tube using a laryngoscope, and 
administration of oxygen and nitrous 
oxide through pressure on the reservoir 
bag, each action responded to by appro- 
priate physiologic responses dictated by 
the computer which controlled the system. 

How this device became a reality is a 
story which provides one more illustration 
of Abrahamson's Formula for Success: 
Dumb Luck! One day in 1964, Tullio 
Ronzoni, an engineer at Aerojet-General's 
Von Karman Center at Azusa, California, 
walked into the office where I was Director 
of the Division of Research in Medical 
Education at the University of Southern 

CADUCEUS ♦ Autumn 1997 ♦ Vol. 13, No. 2 

California (USC) School of Medicine and 
asked a simple question. Ronzoni at that 
time was also a member of a committee of 
the Los Angeles Chamber of Commerce 
charged with finding nondefense activities 
for the aerospace industry, which seemed 
in danger of losing government contracts 
because of the perceived (or should we say 
"misperceived"?) decline in "defense" 
spending. His question was indeed simple: 
"How can we use today's computer 
technology in medical education?" I was 
immediately put off and thought of 
Ronzoni as one more "nut." I was on the 
point of recommending that he go see 
someone else when Ronzoni said, "If you 
can't help me, I'm off to UCLA." 

Those words prompted me to stifle the 
urge to "send him on," and a dialog was 
opened. Perceiving that Ronzoni was 
thinking of something that truly capital- 
ized on the power of the computer in a 
manner similar to that of the Link Trainer 
used to teach pilots how to fly, I proposed 
that a simulation system be devised that 
would provide all of the meters, dials, and 
gauges monitored by an anesthesiologist 
during surgery along with computer 
control so that as the students responded 
to the information provided by the meters, 
dials, and gauges, the system would 
provide accurate responses and thus 
engage the trainee in a simulated training 

Ronzoni liked the concept and then I 
confessed that I had never been inside an 
operating room except when unconscious 
during my own hip surgery and suggested 
consulting J. Samuel Denson, who was 
Chief of Anesthesiology at the Los Angeles 
County General Hospital. Denson, in turn, 
was excited by the concept, and the three 
of us then met with several engineers at 
Aerojet-General, most notably A. Paul 

Clark and Leonard Taback. During the 
course of one of several luncheon 
meetings, someone suggested building the 
whole body, not just the meters, dials, and 
gauges, and in that way expanding the 
simulation to something resembling much 
more closely the actual training situation. 

After determining that the state of the 
art of the needed materials and technology 
(e.g., plastics, computer, animation) was 
indeed adequate for the demands to be 
met, the team went to work on system 
requirements and specifications. Within a 
month or so, the required system was 
described in a proposal with an artist's 
drawing depicting the system— by this time 
called "Sim One." All that was needed 
then was financial support. 

The search for funds in 1964 and 1965 
took the team to any number of bureaus, 
divisions, and sections of the federal 
government, including those in the 
Department of Health, Education, and 
Welfare (HEW), the Department of 
Defense, and the Public Health Service. 
None of these visits resulted in anything 
more than comments like "What a great 
idea" followed by "We don't have money 
for great ideas." On returning to Los 
Angeles, I sat down and wrote a proposal 
and mailed it to the United States Office of 
Education's Cooperative Research Project 
for their consideration. The "team" 
received a favorable response and a grant 
of $272,000. In the summer of 1965, the 
date of the grant, that was indeed a 
substantial amount of money. 

It is interesting to note the circum- 
stances surrounding that grant. Years later 
I met a man who had been a member of 
the committee which reviewed our 
proposal. He told me that the committee 
voted to reject the proposal because 
someone at the meeting said, "The 

30 Sim One— A Patient Simulator 

Original atiist's drawing which accompanied the pant proposal submitted to the United States Office of Education. 
In the summer of 1965, the proposal resulted in an award of $272,000 to Stephen Abrahainson, Director of the 
Division of Research in Medical Education of the University of Southern California School of Medicine. 

damned NIH has all of the money; they 
can fund this thing." At that point this man 
told me that he stood up and said, "The 
NIH will never fund something as innova- 
tive as this; we should do it." And thus, 
Sim One, already conceived, was now in 

Engineering Notes 

The project was designed to demonstrate 
the feasibility of simulating a hiunan being 
for purposes of training physicians (or 
other health-care providers) to perform 
certain clinical tasks involved in health 

care and to show the effectiveness of using 
such a simulator in clinical training. The 
inventors chose the complex task of endo- 
tracheal intubation and induction of anes- 
thesia because it is a demanding procedure 
requiring knowledge and judgment in 
addition to psychomotor skills. Sim One, 
therefore, was constructed to "behave" and 
"respond" as a real human being undergo- 
ing endotracheal intubation and induction 
of anesthesia. 

The first step was to analyze physiologic 
and pharmacologic data to serve as the 
guide for the design of both the manikin 

Stephen Abrahamson 31 

Sim One lying on his operating table. Mechanisms underneath controlled many actions, including breathing 
measurement of intravenous injections, jaw movement, blinking of eyes, "bucking" when anesthesia level gets too 
low, and heart beat. 

and the computer programs. Denson 
provided the necessary data based on his 
experience and his knowledge of the basic 
medical sciences of physiology, pharma- 
cology, anatomy, and pathology. Raw data 
then had to be reviewed and refined into 
manikin specifications and computer 
programs by the engineers. The resulting 
system, Sim One, was expected to simulate 
the following procedures described in 
Medical Engineering: 

Oxygen is administered through mask to the 
patient for a period of 5 minutes in order to 
raise the oxygen level in the tissues and thus 
provide an extra margin of safety during the 
time in which the patient might go without 
oxygen during the next stages of the 
maneuver. Sodium pentothal is administered 
intravenously, which renders the patient 
unconscious. Succinylcholine is injected, which 
produces paralysis of skeletal muscles and 
indeed causes the patient to stop breathing. 
The anesthesiologist then quickly slips off the 

32 Sim One— A Patient Simulator 

mask and inserts the airway tube into the 
trachea, seaHng it inside the walls of the 
trachea by inflating the balloon-like rubber cuff 
of the tube. Through this tube, connected to 
the anesthesia machine, the anesthesiologist 
then administers oxygen and nitrous oxide by 
squeezing the inflated rescnoir bag. During all 
of this activity, Sim One's computer registers 
all of the anesthesiologist's actions and the 
agents administered and dictates the appro- 
priate physiologic responses. At any time, the 
instructor has the option of "overriding" the 
physiologic program in order to produce such 
problem situations as cardiac arrest, abnor- 
mally increased or decreased blood pressure, 
left or right block of the bronchus, increased 
or decreased breathing rate, cardiac 
arrhythmia, ventricular fibrillation, increased 
jaw tension and vomiting!' 

Not only was Sim One able to simulate 
all of the physiologic "behavior" of a real 
human being, he also had anatomic 
authenticity with the following all 
included. Inside the mouth were the 
normal structures: teeth, tongue, palate, 
epiglottis, aryepiglottic fold, esophageal 
opening, and vocal cords visible when the 
laryngoscope was inserted. Breathing 
involved two movements in the body: rib- 
cage expansion of the chest wall and 
diaphragmatic shift toward the abdomen. 

The system consisted of five major 
components: the manikin (constructed by 
the Sierra Engineering Company), the 
computer (Aerojet-General's general- 
purpose hybrid computer), a real 
anesthesia machine (Ohio-Heidbrink 
Model B3303), an instructor's console, and 
an interface unit.^ 

The project was started in the summer 
of 1965, with actual construction 
underway by January, 1966. The system 
was available for testing and refinement in 

January, 1967. Actual studies of its effec- 
tiveness were started during the summer of 

Introduction of Sim One 

Sim One made its official "debut" at 
Columbia University at the annual meeting 
of the Professors of Anesthesiology on 
March 17, 1967. Denson and I made the 
presentation, and two incidents occurred 
during the "unveiling" of Sim One which 
may be of some interest. A special motion- 
picture film was deemed necessary to 
describe the simulator to any audience 
since slides or photographs could never 
convey the "behavior" of the device. Thus, 
our presentation involved narration to 
accompany this silent motion-picture film 
of Sim One for the audience of Professors 
of Anesthesiology. Denson narrated the 
first half, which showed the entire clinical 
maneuver of endotracheal intubation and 
induction of anesthesia performed by him 
on Sim One. At one point, the audience 
was heard to chuckle, causing both of us to 
fear the worst: somehow or other, there 
was something that did not ring true to 
this critical audience. At lunch immediate- 
ly following the presentation, however, 
Denson and I learned what had caused the 
laughter. Apparently, these professors of 
anesthesiology had found themselves hold- 
ing their breath during the time that Sim 
One's breathing had been stopped by the 
administration of succinylcholine and then 
had expelled the air when Denson had 
started the flow of oxygen. The simultane- 
ous expulsion of air by the members of the 
audience apparently caused them all to 
laugh! The explanation was simple 
enough. During the filming, Denson had 
to perform all the steps very slowly in 
order for the film to show the processes 

Stephen Abrahamson 33 

clearly. Thus, although the film appeared 
to be showing the maneuver in real time, 
much more time was taken by Denson 
than a competent anesthesiologist would 
require in an operating room. The point of 
relating this anecdote is simply a confirma- 
tion of the authenticity of the simulation. 

The other incident occurred at a 
luncheon table after the presentation. I 
was asked how much this simulation 
system had cost, the questioner trying— 
apparently— to determine if the simulator 
would be cost-effective. When I reported 
that the grant from the United States 
Office of Education had been $272,000, 
my questioner (a professor of anesthesi- 
ology at a medical school) replied, "It 
doesn't cost nearly so much to train them 
now," suggesting that students— including 
residents— could be trained on real 
(charity) patients more cheaply than on a 
simulator. Denson and I, of course, 
believed that using such a patient 
simulator would save these real patients 
from potential harm and/or discomfort. 
The question of "cost-effectiveness" was to 
become an important issue for Sim One's 

The First Study 

The effectiveness of Sim One was studied 
using twelve new anesthesiology residents 
at the Los Angeles County General 
Hospital. After two residents were elimi- 
nated because of extensive prior experi- 
ence in intubation, the remaining ten were 
"paired" for study purposes: five receiving 
training on Sim One at Aerojet-General's 
Von Karman Center, the other five getting 
their training experience in the operating 
room, without the benefit of "training 
runs" on Sim One. The hypothesis of the 
study was that the residents trained on Sim 
One would arrive at predetermined levels 

of competence (1) in less elapsed time 
from when they started their residency and 
(2) with fewer trials in the operating room 
than their counterparts. The major source 
of data was expert review of anesthesia 
charts which included complete records of 
all anesthesiology procedures during 
surgery. More than twelve hundred charts 
were reviewed by experts who did not 
know which charts belonged to Sim 
One-trained residents. Data confirmed the 
hypothesis: the simulator-trained residents 
arrived at criterion levels of performance 
in significantly fewer operating-room trials 
and in significantly fewer elapsed days 
from the start of training.^ 

More specifically, the study showed that 
"elapsed time in days from the beginning 
of the residency to completion of nine out 
of ten consecutive professionally compe- 
tent intubations in live patients averaged 
45.6 days for the simulator group and 77 
days for the control group. To achieve this 
same level of competence, the simulator 
group required only 30 attempted (actual) 
intubations in the operating room, 
compared with 60 for the control group. "^ 
In addition, those residents trained on Sim 
One were observed making half the 
number of errors in the operating room of 
those made by the control group. 

Follow-Up Work 

The immediate reaction to Sim One was a 
flurry of high-profile attention, including 
articles in Life, Time, and Newsweek, and an 
interview of me on Walter Cronkite's CBS 
Evening News. HEW officials not only took 
a great interest in the project but offered 
to put together a "package" of subsidy for 
continued development from some HEW 
agencies and the United States Office of 
Education. They further suggested that 
Denson and I, as the principal investiga- 

34 Sim One— A Patient Simulator 

J. Samuel Demon, Chief of Anesthesiology at the Los Angeles County General Hospital, stands at Sim One's head 
ready to place the mask over Sim One's face to administer oxygen frojn the anesthesia machine. Abrahamson sits at 
the instructor's console ready to monitor the procedure and to introduce problems such as increase or decrease in 
blood pressure, increase or decrease in heart rate, heart airhythmia. heart arrest, "bucking, " or vomiting. 

tors on the original project, develop not 
just another study but comprehensive 
plans for the future. Together with 
Ronzoni, we laid out plans for a 
"Simulation Center" with projected devel- 
opment of a number of simulators, each 
dedicated to a different set of clinical 
tasks. The plan also included the simula- 
tion of a "complete" patient as the culmi- 
nation of the first seven vears of work. 

Ronzoni even went so far as to identify a 
building in which the center might be 

But such was not to be. With the Viet 
Nam War claiming more and more of the 
national budget, the costs were declared 
too high by the funding agencies, no one 
of which would have been able to claim the 
project as its own. Instead, we were asked 
in 1969 by the newly established National 

Stephen Abrahamson 35 







Three Aerojet-General engineers check out Sii/i One's functions: A. Paul 
Clark, Henn Perez, and Leonard Taback. 

Center for Health Care Research and 
Development to draw up plans to study the 
"cost-effectiveness" of Sim One, stating 
that the original project had merely 
trained five residents on Sim One. We 
pointed out that the original project had 
been a demonstration of the feasibility of 
such a system and was never meant to do 
more. The outcome, however, was clear: 
further support for the development of 
this technology would depend upon a 
study of "cost-effectiveness." 

Until this time, Sim One had occupied 
some four hundred square feet of space at 
the Von Karman Center of Aerojet- 
General. The first step in the new project 
called for modification of Sim One to 
permit moving it twenty-five miles to the 
Los Angeles County-USC Medical Center, 
where the system would be easily accessible 
for training purposes. To do this, Sim One 
had to be "weaned" from the hybrid 
computer system at Aerojet-General and 
attached to a Honeywell H316 "minicom- 
puter" (state-of-the-art at the time and the 
size of a filing cabinet!). The minicom- 
puter and all the other necessary equip- 

ment were mounted in a special mobile 

In order to expand the capability of Sim 
One from training only anesthesiology 
residents to training a broader group of 
health-care workers, a new right arm was 
built, designed to permit, among other 
things, blood pressure measurement, intra- 
muscular injection into the deltoid muscle, 
extraction of blood through venipuncture, 
and catheterization of the vein for the 
purpose of measuring central venous 
pressure (CVP). A number of other 
significant changes were reported: 

A new mathematical model was developed 
to simulate a patient in circulatory failure or 
"shock". The model allows the instructor to 
select various degrees of effective volume loss 
or heart failure, or combinations of both 
parameters. Equations connect CVP, blood 
pressure, heart rate and respiration to the state 
of the internal parameter. The student must 
then administer fluids appropriately in order 
to bring Sim One's CVP and palpable pulse 
contour back to normal. 

Programming changes in the anesthesia 
model allowed two separate respiratory states, 
apneic and depressed, in addition to the 
normal state of respiration. In both states, Sim 
One's ventilation can be assisted by use of a 
mask and bag or by attachment of a respirator. 

In addition, the anatomy of Sim One's oral 
cavity and trachea were resculptured so that 
the vocal cords are fully visible when the head 
is extended for intubation. This last change 
made Sim One suitable for the teaching of 
intubation to students other than anesthesi- 
ology residents.^ 

Sim One's changes made him much 
more valuable because it was possible to 
train many different health-care workers in 
a variety of tasks. Studies were conducted 
during 1970 and 1971 to determine 
whether the use of Sim One reduced costs 
of instruction. Given the difficulty of 

36 Sim One— A Patient Simulator 

Aerojet-General engineer Taback makes adjustments to Sim One's controlling mechanisms contained within the 
operating table. 

assigning monetary "value" to human life 
and/or welfare made the final determina- 
tion of cost-effectiveness almost impossible 
to achieve. Thus, the studies of cost-effec- 
tiveness concentrated on (1) learning gains 
per unit of time; (2) amount of student 
time required to reach criterion levels of 
performance; and (3) the investment of 
faculty time necessary for student 
learning— all variables amenable to reason- 
ably precise measurement. 

The studies indicated that students who 
were trained on Sim One performed 
significantly better than students conven- 
tionally trained and that significantly less 
faculty time was required to bring Sim 

One-trained students up to criterion levels 
of performance. In addition, data were 
gathered on reduction of patient risk but 
were not reported because of the inherent 
subjective quality of assigning value to 
such reduction of risk. Our article in 
Ldkartidningen summed it up quite well. 
"In sum, the University of Southern 
California School of Medicine has found 
that its life-like simulator is a practical and 
effective aid in the training of various 
health-care professionals. Sim One, when 
used efficiently, can save enough in faculty 
hours to justify its cost within a short 
period of time. Most important, the use of 
Sim One reduces the amount of risk and 

Stephen Abrahamson 37 

discomfort to which patients are 

Sim One's Last Days 

Remarkably enough, Sim One was actually 
used for training a variety of health-care 
providers over a period of almost ten 
years. This feat was truly "remarkable" in 
that Sim One had been designed and con- 
structed as a demonstration of feasibility, 
not of utility. The system had not been 
developed for extensive use, but rather for 
demonstration and experimentation. 
Instead, literally hundreds of health-profes- 
sional students were trained under the 
guidance of Kaaren I. Hoffman, who also 
collected and reported effectiveness data. 

These health-care providers included 
nurses, inhalation therapists, medical 
interns, anesthesiology residents, and 
emergency-room personnel. In all cases, 
both students and faculty thought that the 
experience was most useful and 
contributed to their increased competency 
with less risk to patients and less time of 
faculty necessary for student learning. 

Over these years, however, the system 
began to show signs of wear. Having been 
constructed as a kind of "breadboard" 
model with much idiosyncratic 
engineering, Sim One required more and 
more attention by the engineers who 
designed and constructed it, most notably 
Clark and Taback. In addition, the wear 
and tear on the plastic skin began to make 
itself known with little cracks and 
blemishes, which increasingly could not be 
repaired without leaving noticeable marks. 
Through all of this period of gradual 
deterioration, however, training runs 
continued and Sim One was still providing 
trainees with learning experiences which 
held no threat to patients. 

During this period of decline, Hoffman 

and I, with Ronzoni's invaluable support, 
continued to search for funding to further 
this innovative effort. But this was 1975 
and 1976, and the times were against us. 
Between some internal administrative 
problems and a changing national posture 
with regard to support for education, 
outside funding for continuation was not 
found and Sim One's days were numbered. 

Those "internal administrative 
problems" literally killed the future of the 
simulation effort. Ronzoni had managed to 
obtain a promise of additional funding 
from a governmental agency on the condi- 
tion that the request for funding not 
exceed a certain amount and that the 
proposal be submitted by February 1, 
1974. The proposal was prepared under 
the pressure of this deadline and was 
completed as I left the country for three 
months to conduct a workshop in Sri 
Lanka and then to serve as a Visiting 
Professor in the Department of Surgery at 
the University of Adelaide. The proposal 
had to be processed through a USC system 
in which department chairmen had to 
"sign off" if one of their faculty members 
was involved in the project. One such 
chairman refused to sign off because he, 
himself, was not "written in" as a "Co- 
Principal Investigator." By the time the 
Dean of the School of Medicine had 
settled this problem in my absence, the 
deadline had passed and Ronzoni— who 
had carefully arranged the contract— was 
informed that the available funds had been 
used for some other project! 

When I returned, efforts were made to 
bring the two departments together in a 
common effort to locate other funding. By 
the time that the internal problems were 
resolved, however, the funding agencies 
were no longer interested— particularly in a 
project which would take place in a setting 

38 Sim One— A Patient Simulator 



^^ mm 

m/ . 1 

"Proud parents, "Demon and Abraliamson. enjoy a moment of satisfaction with their "bra/nrhild. "Sim One. 

in which there had been such contention 
and conflict. 

The actual final demise of Sim One 
speaks well to the low esteem the academic 
world really was developing for education. 
The simulation system was housed in a 
one-floor barracks-like building just 
outside the Los Angeles County General 
Hospital, in fact called "Barracks G." The 
hospital administration made a decision 
that Barracks G should be converted to an 
administration home for the hospital 
chaplains and ordered Sim One to be 
moved. At the same time, however, the 
hospital administration stated that it did 
not have space to accommodate the system 
(roughly four hundred square feet) and 
requested the School of Medicine to 
provide space— despite the fact that all of 

those being trained on Sim One (hundreds 
per year) were either employees of the 
hospital or others providing care in the 
hospital. The School of Medicine protested 
that it, too, had a shortage of space, and an 
impasse of sorts was reached. 

As luck would have it, while these 
"discussions" were taking place, construc- 
tion was begun on refurbishing the 
barracks for the chaplains. One morning, 
the construction workers broke through a 
wall from a room adjoining the room 
housing Sim One; the workers, of course, 
found this "body" (Sim One) on a table 
and medical equipment all around- 
including hypodermic needles. They 
notified the security office which, in turn, 
called the hospital pharmacist, instead of 
Hoffman or me. That hospital pharmacist. 

Stephen Abrahamson 39 

on hearing that there were hypodermic 
needles "just lying there," ordered the 
security people to bring the needles to 
him— and he proceeded to destroy them! 
Unfortunately for all concerned, the 
needles were magnetically coded in such a 
way that the simulation system could sense 
what was being injected into Sim One. (All 
injected substances were distilled water. As 
the magnetically coded needle was 
inserted into the intravenous portal, a coil 
in that portal "read" the code and 
informed the computer as to what was 
being injected.) These needles were truly a 
sine qua non of the system. Furthermore, 
the needles had been especially prepared 
by a West German company which had 
"gone out of business" in the meantime. 
The needles, thus, could not be replaced; a 
new system would have had to be 
designed— but without fvmds, of course, to 
do so. 

A sad postscript to this sorry tale is that 
Sim One still had to be moved and no 
space was available. While the administra- 
tions of both hospital and school were 
engaged in desultory discussions 
concerning this problem, the system was in 
fact moved to a School-of-Medicine class- 
room which was being used for storage 
purposes. When the manikin on its table 
arrived, it was discovered that it could not 
fit through the door without removing the 
door from its hinges. Instead of doing so— 
or locating another space— the "solution" 
was to "amputate" Sim One's left arm 
along with the part of the table holding 
that appendage! 

Thus passed one of the most remarkable 
innovative teaching aids in all of medical 
education. All that remains is a set of still 
photographs, two motion pictures (one 
silent and a shorter one with sound), and a 
number of journal articles describing the 

simulator and its "contributions" to 
medical education. 

The Future 

And what of the future? Interestingly 
enough, at least two similar simulators 
have been reported in the press— in neither 
case was there mention of the pioneer 
work on Sim One. It was as if all such sim- 
ulation efforts had begun with these new 

Today's technology is far superior to that 
of 1967, when Sim One first appeared, or 
that of 1971, when Sim One was modified 
and moved to its "new" home at the Los 
Angeles County General Hospital. Today, 
the computer needed to govern all the 
action could easily be housed in the 
manikin— or even in the manikin's head, 
like a real "brain." The necessary anima- 
tion could be better than ever, thanks to 
advances in animatronics. The appearance 
of the manikin could be that much more 
lifelike, even including areas that Sim 
One's inventors were unable to achieve: 
changes in skin color in response to lack of 
oxygen, "sweating," and-or "crying"; instal- 
lation of the central-venous pressure 

But none of this will take place until 
funding sources are located. Medical 
education in general is suffering from a 
striking lack of financial support. (Indeed, 
all of education seems to be in this 
position!) It seems tragic that such a 
promising technology is now limited to 
scattered individual efforts by a few 
dedicated educators and does not realize 
the broader significance that it deserves. 
As long ago as 1980, Peggy Wallace and I 
listed a number of advantages to the use of 
Sim One, advantages which apply to any 
such simulations. These included (1) 
"significant reduction in potential discom- 

40 Sim One— A Patient Simulator 

fort or harm to patients"; (2) capability for 
"students to learn from mistakes far more 
readily"; (3) "gradual increase in difficulty 
of situations faced by the learner"; (4) 
providing "real time as a factor, requiring 
students to perform with real urgency"; (5) 
"introduction of emergencies at the push 
of a button"; (6) "training in the manage- 
ment of chronic conditions"; (7) "variation 
in the manikin's response so that the 
student does not become conditioned to a 
one-response format or pattern"; (8) saving 
of "faculty time and/or student time"; and 
(9) standardization of "complex tasks . . . 
for effective, objective assessment of 
student skill level."' 

Perhaps that day will come, the day 
envisioned by Ronzoni and me, when 
every medical school and every teaching 
hospital will have a set of patient simula- 
tors to be used for teaching and testing 
those who provide health-care services. 
Perhaps the emergence of "managed 
health care" will stimulate the develop- 
ment and application of this technolog)' as 
a significant effort to improve training, to 
provide a valid certification mechanism, 
and thus to reduce potential discomfort 
and harm for patients who presently run 
those risks while providing for the learning 
by novice health providers and health- 
professions students. 

?i. Stephen Abrahamson, Judson S. Denson, 
and Richaid Wolf, "Effectiveness of a Simulator in 
Training Anesthesiology Residents," Journal of 
Medical Education 44, no. 6 (June 1969): 515-19. 

4. Judson S. Denson and Stephen 
Abrahamson, "A Computer-Controlled Patient 
Simulator," /AiMA 208, no. 3 (Apr. 21, 1969): 

5. Stephen Abrahamson and Kaaren I. 
Hoffman, "Sim One: A Computer-Controlled 
Patient Simulator," Lakartidningen 71, no. 47 
(Nov. 20, 1974): 4756-58. 

6. Ibid. 

7. Stephen Abrahamson and Peggy Wallace, 
"Using Computer-Controlled Interactive Manikins 
in Medical Education," Medical Teacher 2, no. 1 
(1980): 25-31. 

STEPHEN ABRAHAMSON is Professor Emeritus of 
Medical Education at tlie University of Soutliern 
California School of Medicine. In 1963, he founded 
the Department of Medical Education and served as 
its Chairman until 1991. He has been Chairman of the 
Group on Educational Affairs of the Association of 
American Medical Colleges (AAMC) and President of 
the Society of Directors of Research in Medical 
Education. At the National Board of Medical 
Examiners (NBME) he was Member-at-Large, 
Chairman of the Research Advisory Committee, and 
Chairman of the Liaison Advisory Committee. He has 
been an invited educational consultant to more than 
half of the North American medical schools as well as 
to medical schools in Europe, Africa, Asia, Australia, 
and New Zealand. Recognition of his innovative 
scholarship has included a Senior Fulbright Award, 
the John Hubbard Award from the NBME, the Merrill 
Flair Award from the AAMC, and an honorary 
doctorate from the Medical College of Ohio. His most 
recent book is Essays on Medical Education (1996). 


1. Stephen Abrahamson, "Human Simulation 
for Training in Anesthesiology," in Medical 
Engineering, ed. Charles Dean Ray (Chicago: Year 
Book Medical Publishers, Inc., 1974), 370-74. 

2. For detailed engineering information, see 

Stephen Abrahamson 41 

Virtual coronal plane computer reconstructions from the original, transverse cross sections of the Visible 
Human Project. These images were made by stacking the images (1,878 for the male and 5, 189 for the 
female) and then slicing the resultant stacks from head to foot at the illustrated depth. 

The Visible Human: A New Language 
for Communication in Health Care 

Victor M. Spitzer 

All health care professionals have a 
common underlying problem in 
managing the care of their clients— to 
understand the geometrical relationship, 
structvue, and function of the components 
of a system (the patient) at precise points 
in time (the visit) without disturbing the 

A New Model of Anatomy 

Health care educators have met the 
challenge not only by expanding the 
professional's knowledge about the generic 
human body (anatomy) but also by 
improving methods of gaining anecdotal 
information about the specific body, 
including physical examination and 
diagnostic imaging. 

The development of the model of 
generic human anatomy takes various 
forms for different health care profes- 
sionals. Cadavers have been an important 
part of that training, and variation in 
anatomy is taught by experience with 
different cadavers. The cadaver provides a 
powerful interactive learning experience 
for the student, but it must not be 
overlooked that the cadaver is only an 
approximation to the structure and 
function of the live patient. The majority 
of health care professionals do not have 

firsthand cadaver experience and derive 
their perception of the human body from 
textbooks and classical didactic material. 

The Visible Human affords us the 
opportunity to enhance communication of 
anatomical knowledge to all students and 
to facilitate and promote communication 
between health care professionals (and 
people in general) with diverse back- 
grovmds, levels of training, and complexi- 
ties of vocabulary. It provides a resource 
for visual communication that has the 
potential to better approximate the live 
human than does the cadaver. 

The Visible Human Project 

The Visible Human Project was conceived 
by the National Library of Medicine in 
1986 to create a volume database of male 
and female human anatomy that could be 
computer accessed, controlled, and distrib- 
uted. The technology was developed at the 
University of Colorado School of 
Medicine; the principal investigators were 
David G. Whitlock and the author. Our 
intent was to image whole male and female 
cadavers at thinly spaced intervals. The 
Visible Human Male was completed in 
October 1994. The Visible Human Female 
was completed in October 1995. Together, 
they comprise the Visible Human Dataset, 

C.^DUCEUS ♦ Autumn 1997 ♦ Vol. l.S, No. 2 

Karl Reinig, inventor of the celiac plexus block simulator (an abdominal anesthesia procedure), demoiistrates the procedure at the Center 
for Human Simulation. Holding the needle in his left hand, he views the posterior abdomen and back on the monitor. The plastic shell 
below (which is molded to the exact shape of the Visible Human back) provides authentic haptic seruation. The upper-right image is a three- 
dimensional visualization, from an anterior view, of the structures in the posterior abdomen; the anterior surface of the aorta is the target. 
Behind the plastic back are three motors and an articulated arm (from Sensable Technologies) that are coupled to the Visible Human data 
and provide forces indicative of the needle resistance (letters indicate, respectively, kidney, psoas muscle, inferior vena cava, aorta, and 
ureter). The lower-right image is a posterior view of the posterior muscle and ligament layer deep to the skin and subcutaneous fat. The 
student can feel any of the tissues, either on the correct path to the target celiac plexus or on a path that is completely off target. Ligaments 
conceal the spinal processes (S) of the vertebrae. 

a tradeniarked collection of more than 
thirteen thousand images. The dataset 
includes radiographs, computed tomog- 
raphy images, and magnetic resonance 
images of the intact cadavers as well as 
1,878 male and 5,189 female photographic 
images of thinly sliced cross sections of the 

All images of the Visible Human Dataset 
are related. Each cadaver can be reassem- 
bled and recut in the computer to visualize 
the intact cadaver from any desired cross 
section. The Visible Human therefore 
combines the reality of the original images 
(transverse to the long axis of the body) 
with the students' manipulation of the 
three-dimensional stack of original images 
to produce virtual reality images at any 
angle to the long axis of the body. 

Virtual Reality Learning Through Assembly 

The Visible Human can be disassembled (a 
process called segmentation) by tissue 
characteristics as well as by slices. 
Anatomical structures with unique colors 
or combinations of unique colors 
(textures) can be isolated and distin- 
guished from the rest of the body in order 
to appreciate their size, position, and 
relative location. After tissue-character- 
based segmentation, an anatomist 
identifies or segments anatomical struc- 
tures of a single-tissue characteristic, based 
on function or classical anatomical subdivi- 
sions. Then the user can visualize three- 
dimensional anatomical structures of the 
body regardless of color; individual 
muscles of the same color, for example, 
can be isolated from one another. 

Transverse cross sections from the Visible Human Male (upper) and Visible Human Female (lower). The images are 
photograplis of the original cross sections: lA is a slice through the center of the orbit; IB is the succeeding slice (for 
the male. 1 mm from slice lA; for the female. 0.33 mm from slice lA): IC is a cut through the pelvis; and ID is a 
cut through the knees. 


^.1. (^ 

Victor M. Spitzer 45 

Three-dimensional rendering of the gastrointestinal system. Organ reconstruc- 
tion of the esophagus, stomach, small intestine, colon, and rectum was a two- 
step process of combining views of the isolated and "in situ" systems from both 
the anterior-posterior and lateral views. First, an anatomist individually 
segmented and classified the organs by positional analysis; then, each was 
reconstructed in relation to the whole body. 

With refinements at strategic points, the 
Visible Human will facilitate interaction 
with the body and all of its tissues with 
haptic (feeling), aural, and olfactory 
feedback in addition to the classical visual 
feedback. Our goal is to provide health 
care students with the same quality of 
simulation used for decades in the aircraft 

New Directions for Human Simulation 

Human simulation encompasses the fields 
of anatomy, physiology, pathology, patho- 
physiology, evolution, and development. 
Health care education is now in the 
infancy stages of developing engineering 
models to document the enormous 
panorama of human life. 

The Visible Human Project provides the 
foundation for modeling a single vision of 
the anatomy of a single human at a single 
point in time. The great challenge for 
simulations is the addition of physiological 
models to transform those cadaveric visual- 
izations into lifelike models with 
functioning systems. Further refinement of 
the physiological models will allow the 
visualization of development, thereby 
permitting the transforming of one lifelike 
form into the same form at any time in its 
normal life. 

In an ideal extreme, the Visible Human 
would model from embryonic to geriatric 
stages— from life to death. With further 
expansion of our knowledge base and abili- 
ties, we will model both abnormal develop- 
ment (pathology and pathophysiology) and 
abnormal events (trauma). 

When we have achieved nirvana in the 
world of simulation, we will be able to 
extrapolate or predict different people 
from a single specimen and to control time 
in the model with a precision that illus- 
trates evolution of the species. At such a 
point in time, the effort will most probably 
have exceeded or incorporated the 
combined efforts of the Human Genome 
Project and the resources underpinning 
our exploration of space, but the founda- 
tion for those developments has begun 
with the Visible Human. 

Today, we are finalizing the expansion 
and conversion of our laboratory at the 
University of Colorado School of Medicine 

46 The Visible Human 

Three-dimensional rendering of the lower abdomen and 
quadriceps of the right thigh, illustrating the precise 
texture of those muscles in the Visible Human Male. 
The view was produced by reflecting simulated light 
rays from the "muscle colored" set of data, which illus- 
trates muscles as a tissue category but does not distin- 
guish individual muscles from each other. 


\y-y ' 

Three-dimensional rendering of the skeletal foot. This rendering is possible 
07ily because each bone has been individually segmented and classified by an 
anatomist, not just by such image characteristics as bone density from either 
computed tomopaphy or color from the photographic data. If only image- 
based tissue characteristics were used in the database, all bones would be the 
same shade of gray and thus indistinguishable at many joints. 

to the Center for Human Simulation. The 
general purpose of the Center for Human 
Simulation is to facilitate the collaboration 
of anatomists, radiologists, computer 
scientists, bioengineers, physicians, and 
educators to promote the application of 
the Visible Human and other anatomical 
data to basic and clinical research, clinical 
practice, and teaching. The primary goal 
of the Center for Human Simulation is to 
develop interactions with computerized 
anatomy in virtual space. Among our 
achievements with the Visible Human and 
other data have been surgical cutting, 
needle insertion, dental probing, and 
ophthalmological procedures (all with 
haptic feedback). 

Victor M. Spitzer 47 

As the Visible Human image database is 
developed as a model of human anatomy 
and extended as a visualization of human 
physiology, we will begin to realize its 
potential to teach variations in normal 
human anatomy. Most important, as a 
single electronic representation of the 
body— with all its variations and forms— the 
Visible Human will facilitate cross-discipli- 
nary understanding and cooperation 
through more efficient communication. 
Unlike a single cadaver (which is experi- 
enced by few) or a textbook or software 
(which is normally targeted at a focused 
audience), the Visible Human Dataset and 
its derivative forms can be used in visual 
commtmication throughout the health care 
industry and beyond. 

VICTOR M. SPITZER is Associate Professor in the 
Departments of Cellular and Structural Biology and 
Radiology at the University of Colorado School of 
Medicine, Denver. His formal training was in mathe- 
matics, physics, chemistry, and nuclear engineering. 
His professional experience is in radiological 
Imaging and anatomy. The raw data for this work is 
from the Visible Human Project, for which he was 
Co-Principal Investigator with David Whitlock from 
1991 to 1995. Extension of this work to other speci- 
mens and the utilization of this and future data is the 
goal of the Center for Human Simulation at the 
University of Colorado, which he directs. The Visible 
Human Project was recognized by the 1996 Satava 
Award at the Medicine Meets Virtual Reality 
Conference for "transformation of medicine through 
communication" and by the Bonfils-Stanton 
Foundation Award in recognition of "unique contribu- 
tions in the field of science. Including medicine." 
Utilization of the Visible Human Project by health 
care professionals, other disciplines, and the general 
public for communication of anatomical knowledge— 
from primary schools to adult education— is his 

Additional Information on the Visible Human 

For a summary of the Visible Human Project, including every male photographic 
anatomy image from the dataset, see Victor M. Spitzer and David G. Whitlock, Atlas of 
the Visible Human Male: Reverse Engineering of the Human Body (Sudbury, Mass.: Jones 
and Bartlett Publishers, 1997), available from the publisher's website, 

Additional background on the history and implementation of the project can be 
found in Victor M. Spitzer, Michael J. Ackerman, Ann L. Scherzinger, and David G. 
Whitlock, "The Visible Human Male: A Technical Report," Journal of the American 
Medical Informatics Association 3, no. 2 (1996): 118-30. 

Both male and female images of the dataset are available on the internet. The trans- 
verse images are free, with a license, from the National Library of Medicine. For 
details on both the original data and major products using the data, see the Center 
for Human Simulation website at 

The Visible Human Male data (in 24-bit form), as well as the classification masks, 
can be purchased from the Gold Standard Multimedia website at 

JPEG compressed data can be obtained from the Research Systems, Inc., website at 

48 The Visible Human 

Medicine Beyond the Year 2000 

Richard M. Satava and Shaun B.Jones 

Thanks to a rapid infusion of informa- 
tion technologies (ITs), miniature 
optics, sensors, noninvasive diagnostics, 
and robotics, modern medicine— most 
notably surgery— is undergoing an 
upheaval whose dimensions are not fully 
appreciated even by its practitioners. 

A leading driver of such technical 
advances is laparoscopic surgery, a 
"minimally invasive" surgery in which 
slender probes mounting tiny cameras and 
long hand-controlled surgical tools are 
inserted into the body through a tiny 
incision. With laparoscopic procedures, 
the surgeon operates without directly 
seeing or touching the tissue, unlike tradi- 
tional open surgery. Although laparo- 
scopic svugery was first used in 1986 for 
gallbladder surgery, it is rapidly evolving to 
meet many needs in modern medicine. By 
adding high-resolution noninvasive 
imaging taken before or during the opera- 
tion, for example, a laparascopic surgeon 
can see more detail and visually access 
more difficult surgical problems than is 
possible in traditional open surgery. 

Today, laparascopic surgery also exploits 
another advance: virtual reality (VR). VR 
puts the viewer— a surgeon, physicist, 
engineer, data manager, or student— into a 
computer-generated synthetic environment 

with realistic, moving three-dimensional 
(3-D) images. VR not only supports all 
phases of surgery but can be used to 
predict potential outcomes. A surgeon can 
plan an operation, explore alternatives, 
and rehearse procedures virtually before 
performing them. An orthopedic surgeon 
can predict future wear patterns in a 
repaired joint. A cosmetic surgeon can 
predict aging in a facial skin patch. 

By drawing on VR, generic image data, 
and patient-specific data (including preop- 
erative and intraoperative computer- 
assisted scans), a surgeon can create an 
accurate 3-D representation of a patient's 
target area. Thus, by using tiny actuators 
and other tactile devices, the surgeon can 
"operate" on the VR image of a damaged 
organ; VR will even provide the "feel" of 
the organ as if in traditional open surgery. 

Virtual Reality in the Classroom and Clinic 

VR and improved tactile devices open up 
another market: surgical simulators for 
training and accreditation. Simulators 
permit a broad array of surgical experience; 
they boost productivity and reduce instruc- 
tional costs by letting students practice on 
simulated "virtual humans" instead of 
scarce, costly cadavers or animals. 
Computer-hosted simulators with multi- 

CADUCEUS ♦ Autumn 1997 ♦ Vol. 13, No. 2 

The opinions or assertions contained herein are the private views of the authors and are not to be construed as 
official or as reflecting the views of the Department of the Army, the Department of the Navy, the Advanced Research 
Projects Agency, or the Department of Defense. 

media curricula not only could replace live 
classroom instruction but could be distrib- 
uted over telemedicine networks for 
distance learning and continuing medical 

Future payoffs of surgical VR include 
telemedicine and virtual teams. High- 
bandwidth data links and high-fidelity 
optical and tactile sensors will let 
geographically separated surgeons form 
virtual teams for telesurgery on distant 
patients. VR-aided telesurgery, which is 
being pursued by U.S. military services, 
may revolutionize battlefield medicine and 
medical care in civilian disasters. 

In short, VR-aided surgery has a bright 
future. After lagging behind such profes- 
sions as engineering in using ITs and 
computers, surgery promises to become a 
technological pacesetter, thanks to growing 
synergy with a commercial IT market 
where new products can emerge in months 
rather than years. Moreover, emerging 
capitation-based markets increasingly will 
reward advances in lower-cost, minimally 
invasive outpatient surgery over traditional 
open surgery. 

The VR Interface and the Coming Surgical 

The video monitor is the focal point for 
modern laparascopic surgery, advances in 
VR, digital imaging, 3-D scientific visualiza- 
tion, networking, and electronic databases. 
The monitor is the surgeon's primary 
interface with both the real patient and the 
patient's digital representation, which is 
generated from pre- and intra-operative 
data and imagery streams that may be 
imported during surgery. Other interface 
options include holograms, palmtop 
computers, or— especially for VR— helmet- 
or head-mounted displays (HMDs) that 
position a mini-display in front of each eye. 

The DataGlove and a head-mounted display developed 
by Telepresence Research 

In essence, the surgeon's monitor and 
other sensory interfaces are becoming the 
single most critical tool in surgery. A major 
advance in interface technology will be 
voice control for "hands-off" control in 
complex procedures. A first-generation 
voice control system is used in a robotic 
endoscopic camera holder, which can be 
trained on a specific voice. 

Minimally invasive surgery has exploited 
VR techniques that were pioneered by the 
National Aeronautics and Space 
Administration for training astronauts in 
complex remote-control activities. The 
HMD is frequently used with the Dataglove 
with fiber-optic sensors. Thus, pointing in 
a direction, the operator can move around 
in the world, "fly" through simulated 
objects, and pick up or move simulated 

50 Medicine Beyond the Year 2000 

Five factors contribute to the realism of 
virtual surgery simulators: 

1. fidelity, which requires high-resolution 

2. variation in organ properties, including 
deformation from morphing and kinematics of 

S. simultaneous organ reactions, including 
bleeding from an artery and bile leakage from 
the gallbladder; 

4. interactivity of surgical instruments and 
organs; and 

5. sensory feedback, both tactile and force.' 

The two broad categories of VR are 
exocentric ("through the window") VR, in 
which a person looks into the virtual world 
from an outside vantage point, and immer- 
sive or egocentric VR, in which a person 
feels completely immersed in a virtual 
world. For surgeons, an immersive environ- 
ment might be the interior of an artery, a 
body cavity, or a specific organ. Interfaces 
for immersive VR environments may offer 
aural and tactile interfaces, including, for 
example, sound pitch to convey proximity. 

Immersive environments that are 
described as synthetic (vs. "virtual" environ- 
ments) are being developed for high-end 
uses, including medicine, by companies 
like MiiSE, Inc., of Albuquerque, New 
Mexico. That company has drawn on 
technologies from the Department of 
Energy (DoE) to develop a "multi-user 
synthetic environment" (MuSE) tool. By 
displaying those images on high-perfor- 
mance video monitors or other display 
interfaces, today's "digital physician" has 
access to a full digital representation of the 
patient. He or she has available, during 
surgery if necessary, a full set of patient 
data, including diagnostic imagery, video, 
and textual data. 

With such data richness, a VR interface 

gives the surgeon vmprecedented power in 
data access and manipulation. The 
surgeon can import computerized scans of 
the patient, including scans conducted 
during surgery, and fuse them with real- 
time video images for "X-ray vision." 
Before doing a procedure, the surgeon can 
use the workstation or HMD to practice on 
a virtual patient and then flip a switch and 
use the same interface to work on a real 

Maximizing Image Computing Power and 
Touch Sensations. Due to limited computer 
power, surgical VR simulators have needed 
to trade off desired features— sacrificing, 
for example, graphical realism for high- 
fidelity interactivity. In their study of 
media displays, J. Coleman, C. C. Nduka, 
and A. Darzi have shown that VR displays 
offer between two to fifteen frames per 
second, depending on image complexity.- 
By comparison, video cameras and televi- 
sions can run twenty-four to thirty frames 
per second. The low-frame speeds derive 
from the computationally intensive 
computer generation of VR objects. 
Typically, 3-D virtual objects are made up 
of two-dimensional polygons. Realistic 
computer-generated reconstruction of the 
abdomen, for example, requires five 
hundred thousand polygons per second for 
realistic images. Higher rates are needed 
for magnetic resonance imaging (MRI) or 
computer tomography (CT) images. 

Coleman and colleagues also identify 
improvements in high-fidelity tactile or 
haptic sensors and actuators that give VR 
organs and tissues the feel of the actual 
counterparts, including responses to a 
surgeon's probing, tugging, cutting, and 
suturing actions. Those devices represent 
one of the toughest challenges in surgical 
VR, as they must convey to the surgeon the 
shape, position, texture, temperature, 

Richard M. Satava and Shaun B.Jones 51 

force, and firmness of organs and tissue 
with high spatial accuracy. The TeleTact 
Glove, developed by the Advanced 
Robotics Research Centre of Salford, 
United Kingdom, simulates pressure on 
fingers and palm by inflating tiny 
computer-controlled air bladders. Other 
devices place small vibrating transducers 
on the skin to generate discrete sensations 
and surface textures; they do not replicate 
pressure, however. Full tactile/haptic 
fidelity may require an operator-worn 
exoskeleton, which adds to cost and 

Commercial and Governmental Programs that 
Drive Surgical VR 

The VR revolution in medicine is being 
speeded by several simultaneous advances 
in various technical sectors, all moving 
quickly from lab to market. Many of those 
developments, although nonmedical, have 
significant implications for medicine. 
Commercial drivers include rapid growth 
in high-bandwidth data and Internet links. 
Cable companies in some cities offer cable 
modems with ten megabyte per second 
data rates— considerably faster than current 
intercity "Tl" (1.5 megabytes per second) 
high-speed links. Some arcades make use 
of such cables by participating in VR 
combat games between geographically 
separated teams. 

Modern flight simulators are so realistic 
that simulator-induced nausea is a recog- 
nized hazard. The "distributed simulators" 
of the U.S. military services allow 
members of a special-forces squad to 
practice their mission, use the latest 
imagery of an enemy target or other objec- 
tive, then climb into their helicopters for 
the real mission. 

Remotely controlled experiments and 
distributed virtual teams are crucial 

elements of undergoing federal research. 
The DoE-sponsored Distributed 
Collaboratory Experiments Environment 
(DEEE) project combines high-capacity 
data links with an immersive- VR roomlike 
environment (known as CAVE) whose 
development was funded by the DoD and 
the National Science Foundation (NSF). 
The DEEE will allow multiple labs to team 
on complex experiments at remote sites. 
VR data links for such experimental 
environments have been used over transat- 
lantic distances.^ Similar techniques for 
virtual prototyping and agile manufac- 
turing are also being explored. Multisite, 
interagency collaboration reportedly is a 
major element of those programs.^ 

User interfaces represent another area 
of advance. Flat-panel HMDs and tradi- 
tional monitors are improving, with new 
designs offering extremely high resolution 
that approaches photographic quality. 
Developmental computerized voice-recog- 
nition systems can respond to words in 
various languages or dialects. 

Instructional Simulators and Telesurgery 

VR may offer the greatest benefits in 
medical education and training, with 
telesurgery another important beneficiary. 
The U.S. government is funding work in 
both areas. 

Surgical Training Simulators. The training 
of thousands of surgeons around the world 
in minimally invasive surgery has tradition- 
ally depended on the use of pigs. That 
method is not only expensive but relies on 
a limited number of experienced teachers. 
According to Mark D. Noar, the learning 
curve for such procedures as laparoscopic 
cholecystectomy typically requires fifty 
trials.^ Until that point is reached, 
according to Noar, the minimally invasive 
practitioner may have a sharply increased 

52 Medicine Beyond the Year 2000 

complication rate.^ 

Laparoscopic surgical simulators can 
reduce those risks. David Ota and others 
have noted that since competence assess- 
ment involves rule-based judgment, incor- 
porating so-called fuzzy logic in VR-based 
teaching simulators allows measurement of 
student progress." 

VR supports both didactic and experien- 
tial teaching. In the first mode, it can 
provide 3-D visualization of basic anatomy 
and physiological principles. It then can 
switch to an experiential or exploratory 
mode to reinforce what the student has 
learned. By "seeing" shock realistically or 
by traveling through the lymphatic or 
circulatory system, a student grasps more 
than he or she could from reading books, 
watching blackboards, or dissecting 

Moreover, such instruction can combine 
3-D imagery with a fourth dimension: time. 
A multimedia VR system developed by 
Helene M. Hoffman of the University of 
California at San Diego enables students to 
"fly" into the stomach and grab an ulcer 
for biopsy.^ That action can trigger 
retrieval of the ulcer's histologic micro- 
graph or a videotape of preferred 
techniques for ulcer removal. 

Another critical role for simulators is in 
evaluating a surgeon's performance. 
Embedding performance measures in the 
simulation software allows for competence 
assessment. Algorithms developed to 
coach students in real time can also be 
used to collect historical data on how a 
practitioner's skills are holding up. The 
American College of Surgeons is evalu- 
ating the potential of simulation-based 
training for surgical resident education 
and continuing medical education credits.^ 

Simulators for instruction in laparo- 
scopic surgery have been on the market 

since 1993. Two VR simulators developed 
by Kevin Woods'" and David Hon" 
compiise a simple mannequin into which 
the handles of laparoscopic instruments 
are mounted, providing force feedback. A 
virtual abdomen with liver and gallbladder 
is represented on the video monitor. 

A Laparoscopic Surgical Skills Simulator 
(LSSS), developed by Ixion from Noar's 
work at St. Joseph and Franklin Square 
Hospitals in Baltimore, is described as a 
"completely interactive simulator that uses 
open-ended learning with staged skills 
pedagogy."'- It includes a touch-screen 
monitor and a molded torso with skin that 
duplicates the feel of instrument penetra- 
tion. LSSS exposes students to three 
patients with eleven different problems. Its 
physics-based graphic modeling system 
uses polygons to model organs and then 
welds together high-resolution background 
images through special "video plane 
programming" and image projection. LSSS 
also employs a unique proprietary 
"nonmechanical variable tactile resistance 
device" to simulate both the feel of tissue 
resistance to cutting or probing. 

A different path undertaken by one of 
the authors in collaboration with VPL, 
Inc., of Redwood City, California, 
employed the DataGlove, an HMD, a 
virtual scalpel, clamps, and a VR represen- 
tation of an abdomen.'^ Students can 
virtually fly through the abdomen to learn 
basic physiology. 

A laparoscopic cholecystectomy 
simulator aimed at clinics is the Virtual 
Clinic from the Cine-Med Corporation of 
Woodbury, Connecticut. The Virtual 
Clinic simulates a fully textured liver, 
gallbladder, related structures, and four 
laparoscopic instruments. The tactile 
feedback of the Virtual Clinic has been 
described as "amazingly realistic."'^ Future 

Richard M. Satava and Shaun B.Jones 53 

versions will include such landscapes as the 
abdomen, thorax, pelvis, and heart, 
complete with CT and MRI imagery. 

Making VR Equipment Unobtrusive 

Creating user-friendly equipment has been 
a major challenge for designers of surgical 
VR simulators. Doctors, after all, wish to 
focus their attention on the patient and 
not on the HMDs, datagloves, body- 
tracking suits, or exoskeletons. 

One tack taken by Germany's National 
Research Center for Computer Science is a 
simplified "Responsive Workbench" 
tabletop VR environment.'^ Developed 
with input from physicians, the Responsive 
Workbench projects a virtual human with 
semitransparent skin for surgical planning. 
Wearing a dataglove, the user can manipu- 
late the body in any way— even extract a 
bone for examination! One workbench 
variant simulates ultrasonographic exami- 
nation of a beating heart. The user can 
rotate the model to view the heart from 

different angles and also view it from 

User-friendly design can exploit the fact 
that most of today's medical students are 
highly computer-literate from years of 
playing interactive computer games. 
Moreover, commercial and military devel- 
opers of VR can exploit current trends in 
miniaturization and embedded intelligence 
for interfaces, displays, voice control, and 
body- or motion-tracking sensors. 

For example, one display method that 
goes beyond current HMDs and other flat- 
panel displays is the virtual retinal display 
(VRD) under development by the Human 
Interface Laboratory of the University of 
Washington at Seattle.'^ Funded by the 
Defense Advanced Research Projects 
Agency (DARPA), that work focuses on 
projecting individual image pixels directly 
into a viewer's retina, which creates the 
illusion of a translucent computer screen. 
The VRD mounts on an eyeglass frame or 
some other platform. 

Virtual anatomy 
of the abdomen 
with instruments 
supplied by the 
"Virtual Clinic" 
of Cine-Med 

54 Medicine Beyond the Year 2000 

.4 "virtual 
cadaver" as 
displayed and used 
by students for an 
anatomy lesson at 
Institute, Stuttgart. 

Research on improved display 
techniques for medical databases is also 
underway at the Human-Computer 
Interaction Laboratory University of 
Maryland, College Park. The center is 
developing methods to quickly retrieve 
images from the Visible Human Dataset of 
the National Library of Medicine.'' 

Software Engineering for tfie Digital Physician 

State-of-the-art software currently endows 
physically-based organ models with 
morphing and elasticity properties. 
Prototype software is being tested in 
medical teaching hospitals for outcomes 

A leader in the field of medical software 
engineering is HT Medical, Inc. (formerly 
High Techsplanations) of Rockville, 

Maryland, which calls itself "the world's 
only company focused exclusively on VR 
medical simulation software." The 
company creates VR software for simula- 
tion of interventional radiology (catheteri- 
zation, stent deployment, and angioplasty), 
vascular access (intravenous insertion and 
blood drawing), battlefield injury treat- 
ment, specialized instruction in cardiology 
and gastroenterology', and general instruc- 
tion in endoscopy, urology, neurolog)', and 
gastroenterology. ' *^ 

At a March 1996 demonstration of an 
HT Medical, Inc., VR simulator, radiolo- 
gists manipulated catheters, guidewires, 
and sheaths (through which interventional 
radiology instruments could be passed). 
The simulator tracked all three devices as 
well as the feel of each as it encountered 

Richard M. Satava and Shaun B.Jones 55 

An HT Medical, 
Inc., virtual 
reality simulation 
for training in 
vascular surgery 

various conditions inside blood vessels. A 
radiologist could virtually inject dyes for 
angiogram of blood vessels, treat a 
blockage with angioplasty, or administer 
clot-busting drugs by catheter. The 
simulator is programmed to respond to 
errors with appropriate "complications," 
including balloon ruptures, punctured 
blood vessels, and atherosclerotic plaque in 
older patients. A second-generation HT 
Medical, Inc., angioplasty simulator 
featured a computer with enough power to 
display fifteen frames per second of 
adequately detailed vasculature for 
extremely accurate physiological modeling. 

Virtual Humans as VR Data 

Realistic data for surgical simulators can 
be taken from patient-specific images or 
from databases. Patient-specific CT and 
MRI data can be acquired before the 

operation or, in an emerging trend, even 
during the operation itself. Magnetic 
resonance fluorescence imaging, which 
offers image refresh rates as low as .5 
seconds, is being used for real-time 
guidance of microsurgical instruments. 
Douglas A. Ortendahl and Leon Kaufman 
report that such feedback is extremely 
useful in abdominal procedures, where 
organs are in motion due to respiration.'^ 
While not perfect, it represents the first 
steps toward the realization of real-time 
MRI image-guided surgery. 

N. D. Thalmann and D. Thalmann have 
described the usefulness of virtual humans 
in plastic surgery, where analysis of facial 
expressions and musculature is critical, 
and in orthopedics, where prosthesis 
design, the interaction of artificial joints 
with walking or other motion, and 
outcomes analysis (including outcomes 

56 Medicine Beyond the Year 2000 

analysis during the surgery itself) are 
crucial.^" The premier source of photo- 
tomographic data is the Visible Human 
Project, described elsewhere in this issue.-' 

Remote Surgery, TeleSurgery, and 

While laparoscopic surgery couples the 
surgeon's hand directly to the instruments 
at the end of the probe, telesurgery repli- 
cates the process in a "distance" mode. It 
uses sensors to detect hand motion, 
converts that motion to electronic signals, 
transmits the signals to a remote operating 
site, and converts them into laparoscopic 
tool responses. 

Among current examples of telesurgical 
systems and research programs are the 
Green Telepresence Surgery System, the 
DoD telesurgical methods for battlefield 
casualty care, the Massachusetts Institute 
of Technology (MIT) system for eye 
telesurgery, and telementoring programs 
for distance monitoring of surgical proce- 

The Green Telepresence Surgery System. The 
Green Telepresence Surgery System is a 
remotely-controlled system that addresses 
three problems in laparoscopic surgery: 
lack of sensory feedback, poor dexterity, 
and absence of 3-D vision. The Green 
System features a remote operative site 
equipped with a stereoscopic camera and a 
dexterous manipulator. A surgical worksta- 
tion adjacent to the operative site is 
equipped with a 3-D monitor and instru- 
ment handle controllers whose feedback 
and dexterity resemble those of open- 
surgery instruments. The patient may be 
nearby or at a remote site (e.g., a 
battlefield or space station). 2- 

By importing and overlaying diagnostic 
imagery on the video image, the Green 
system enables a surgeon to operate in 

open-surgery mode. Image fusion is also 
useful for endoscopic or microscopic 
surgical procedures. The Green System 
workstation can import VR simulations as 
well. The current one-handed Green 
System offers five-degrees-of-freedom 
dexterity and uses paired cameras for 
stereo vision. The next generation will 
have two six-degrees-of-freedom surgical 
hands and will replace the cameras with a 
stereoscopic laparoscope. 

Battlefield Casualty Care. The most 
aggressive development of telesurgery is in 
the area of battlefield casualty care, funded 
by the DoD. VR simulation under that 
program emphasizes ballistic wounds, 
bone fragmentation, and other aspects of 
wounds from high-speed metal objects. 
Simulations now run at twelve to fifteen 
frames per second, with a goal of thirty 
frames per second. Unique elements 
include robotic operation on patients 
inside an armored medical vehicle situated 
near the front lines, fast-paced operations 
in which remote telesurgeons tackle only 
the most critical problems (leaving lesser 
problems and patient preparation and 
aftercare to forward medics), and simula- 
tors tailored for combat medics. 

A combat medic might train on a 
simulator using an HMD while sitting on a 
machine resembling an exercise bike that 
moves him across his simulated terrain. 
When he "sees" a soldier fall, he moves 
over to tend him. Kneeling over him, his 
HMD shows a high-fidelity image of the 
battle wounds for which he is training. The 
medic stabilizes the soldier, places him in a 
special transport pod, and moves on to his 
next casualty. 

Eye Telesurgery at MIT. An experimental 
ophthalmology surgery system pioneered 
at MIT is based on high-fidelity 
master/slave interactions. Through such 

Richard M. Satava and Shaun B.Jones 57 

The eye telesurgery 
system, including 
virtual reality 
trainer, perfected 
at the 

Institute of 

advanced telesurgery, MIT surgeons 
perform retinal procedures with 10-micron 
accuracies on moving eyes. The unit 
converts hand motion to electronic signals 
for computer-aided teleoperation. A 
computer tracks patient eye motion of two 
hundred cycles per second and adjusts the 
surgical instrument's motion to the eye 
motion. Filters remove any tremors from 
the surgeon's hand. A major element of 
the work is "microsurgical robots," which 
operate in a master/slave relationship to 
the surgeon. One eye surgery simulator 
employs an "active mannequin" whose eyes 
have tissuelike elastic polymers for realistic 
feel and fast-response artificial muscles for 
movement. 2^ 

A computer reduces master/slave 
motion by 100:1 and impedes unsafe 
movements (an overly rapid movement, for 

example). Blood lines and other features 
can be modeled from different viewing 
perspectives— as one-dimensional lines, for 
example, when viewed from outside but as 
3-D tubes when viewed from inside the 

Telementoring. Telementoring represents 
another payoff of high-bandwidth commu- 
nication links. Tests by a Brady Urological 
Institute team at the Johns Hopkins 
Medical Institutions in 1995 produced a 
95.6 percent success rate (twenty-two of 
twenty-three cases), with an experienced 
surgeon monitoring an inexperienced 
surgeon more than one thousand feet 
away. The experiment featured real-time 
video, two-way audio links, a robotic arm 
to control the videoendoscope, and a 

An even more impressive test was 

58 Medicine Beyond the Year 2000 

conducted in 1996, using satellites and 
landline, between The Netherlands and 
Hawaii. One problem was a modest time 
delay that, while acceptable for telemen- 
toring, could become a more serious issue 
if robotic instrument manipulation was 

Other Surgical Uses of Virtual Reality and 
Related Technologies 

Robot-assisted surgery, telesurgery, nonin- 
vasive diagnostics, training simulators, and 
rehabilitation aids suggests the variety of 
innovation across a broad medical front. 

Brain Surgery and Radiation Therapy. 
Robotics and 3-D image fusion have been 
especially useful in brain surgery. New 
techniques are being demonstrated by 
image-guided stereotaxic resectioning of 
brain tumors by Raymond Sawaya and 
others at the M. D. Anderson Cancer 
Center of the University of Texas at 
Houston. Among the achievements is a 
frameless stereotactic system— the 
Unimation PUMA 200 robot, developed by 
Y. S. Kwoh. The computerized arm of that 
robot adjusts probe trajectories in various 

A related development is the computer- 
ized "viewing wand," a CT-stereotactic 
device developed by Patrick J. Kelly for 
frameless devices, which continuously 
provides the location of the operating site 
in the brain and directs the surgeon 
toward that target.-"^ It also works as a 3-D 
space-monitoring device. The wand has a 
freely mobile, articulated mechanical arm 
attached to a computer that holds the 
patient's preoperative imaging data. The 
computer interactively displays CT or MRl 
images of the patient as a reconstructed 3- 
D model or as an orthogonal formatted 
image. The surgeon uses the mechanical 
arm to touch a series of reference marks 

on the patient while the computer displays 
a model of the probe in relation to the 3-D 
model or the reformatted anatomical 
display. The surgeon marks the corre- 
sponding points on the 3-D model then 
"locks" the patient and model image 
together. The wand's maximum detection 
error is reported as 2.5 mm. It is rated 
particularly useful for skull base surgery, 
which is an extremely complicated 
anatomic region. The wand is ideal for 
navigating to and resectioning the tumors. 

Another stereotactic system from Kelly 
and associates, called Compass, combines 
a microscope, laser tools, and computer 
simulation for image-directed excisions of 
tumors. It provides a heads-up display of 
CT- or MRI-defined tumors obtained 
through a microscope. Compass encircles 
the patient's head during CT, MRI, and 
angiographic imaging and creates 
computer-generated 3-D maps of the 
tumor. During subsequent surgery with a 
robotic device, the device's head-holding 
reference system holds the head in the 
same position that was used for image 
collection. The surgical field thus corre- 
sponds to the computer-generated slice 
images of the field. 

Similar use of image fusion is employed 
during neurosurgery on deeply embedded 
brain tumors by surgeons at Brigham 
Women's Hospital, Boston. Ferrenc A. 
Jolesz overlays MRI images with video 
images to locate tumor margins within 0.5 
mm accuracy.-^ Meanwhile, Henry B. 
Fuchs of the University of North Carolina 
has built a VR model that lets a radiothera- 
pist visualize a tumor, reconstructed from 
3-D CT scans, inside the patient.-^" He can 
then plan radiation trajectories that give 
lethal doses to the tumor while not 
damaging normal organs. 

Maxillo-Facial Surgery and Virtual 

Richard M. Satava and Shaun B.Jones 59 

The virtual 
reality simulation 
of tendon 
developed by 

Endoscopy. The use of 3-D images and 
models have brought major advances in 
plastic surgery. At Brigham Women's 
Hospital, David E. Altobelli created 3-D 
images from the CT scan of a child with 
craniofacial dysostosis, a bony deformity in 
which only half of the face grows. In what 
is normally an extremely difficult proce- 
dure, the surgeon used the 3-D model to 
rearrange the bones to symmetrically 
match the healthy side of the face."*' 

At the Dartmouth University Medical 
Center, Joseph M. Rosen uses a VR model 
of a face with deformable skin for 
practicing plastic surgery procedures and 
predicting outcomes before he makes his 
first incision on a patient.''- 

Similarly, MusculoGraphics, Inc., of 
Evanston, Illinois, offers a family of SIMM 
(Software for Interactive Musculoskeletal 

Modeling) virtual models that calculate 
joint movements that limb muscles can 
generate at any body position.^'' The firm's 
Computer-Assisted Surgery systems 
simplify and automate many surgical 
procedures. A surgeon performing a 
tendon transplant on a lower leg, for 
example, can use SIMM/Gait to "walk" the 
leg in order to predict short- and long-term 
surgical outcomes. For the DoD, 
MusculoGraphics is developing a Limb 
Trauma Simulator that models gunshot 
wounds to the leg. 

At the GE Medical Corporate Research 
Center, William E. Lorensen and others 
have developed a "virtual endoscope" that 
lets a physician view internal surfaces from 
any perspective, including from behind 
tissue folds or around difficult flexures. 
The technique lets a doctor look through a 

60 Medicine Beyond the Year 2000 

tumor to determine penetration of the 
wall or detect metastases. By incorporating 
multispectral analysis of the image, the 
technique offers an "optical biopsy" that 
could replace current flexible endoscopic 
examinations. The method would also be 
beneficial to other medical disciplines, 
especially urology, pulmonology, and ear- 
nose-throat. "^^ High-accuracy virtual 
endoscopy holds promise for both medical 
education and telesurgery. 

Rehabilitation and Assistive Devices. 
Virtual environments have become so 
useful in rehabilitative medicine that an 
annual conference is held on the subject. 
Virtual environments have been created 
for exploration from a wheelchair.''^ A 
specialist using a BioControl, Inc., eye- 
tracking device has allowed a quadriplegic 
girl to interact with the outside world 
before her disability causes her to become 
too introverted to communicate.'^*^ 

The use of immersive VR for cognitive 
rehabilitation of brain-damaged patients is 
under study by an halian team under a 
project called ARCANA (Advanced Re- 
search for the Computer-based Assessment 
of Neurophysiological Ailments). 
ARCANA uses VR models to help clinical 
psychologists, neurophysiologists, and 
cognitive therapists work with cognitively 
impaired people.^" German research 
laboratories are perfecting datagloves, 
biosignals, and other VR techniques that 
will facilitate communication for the physi- 
cally challenged.^'"* 

Data Visualization. VR can visualize 
extremely large data fields, such as medical 
databases. Intelligence and government 
agencies are technical leaders in data 
visualization, image processing, and other 
techniques that let analysts rapidly scan 
such data fields. One example is a 3-D 
representation of war injuries recorded in 

"Operating Environment of the Future" as envisioned by Xorthrop Grumman 

the Viet Nam Database. By using three 
axes of information, researchers can 
visualize as clusters complex combinations 
of wounds, organs injured, mortality, and 
other data.^^ Surgeons can draw on 
research and development activities in IT 
by the U.S. intelligence community, the 
government, and contracting commercial 
and academic developers. 

Surgical Facility Design. Another medical 
use of VR— designing the operating room 
of the future— is being pursued by the MIT 
School of Architecture and the Harvard 
Graduate School of Design. ^'^ A team from 
both schools is assessing new spatial 
arrangements, the use of smart materials 
and intelligent equipment, and the integra- 
tion of information sources, imaging 
systems, and new treatment modalities. VR 
will be used for end-to-end planning of the 
operating room, allowing hospital admin- 
istrators, surgeons, anesthesiologists, 
technicians, and others to test the facility 
in virtual form before it is built. 

Richard M. Satava and Shaun B.Jones 61 

Future Developments and Issues for Medicine 
in the Year 2000 

Information technologies and laparoscopic 
surgical techniques have begun the revolu- 
tion in medical technology, but it is far 
from complete. On the technology side, 
improving the accuracy of VR organ 
models is considered critical. That 
includes measuring tissue properties to get 
a simulation baseline. 

Adding intelligence to the pixels (the 
tiny "picture elements" of a display) would 
allow the addition of dynamic changes in 
certain organs. The technique called deep 
pixels could let every pixel store massive 
amounts of information, such as anatomic 
function, color, texture, dynamic 
movement, physiologic parameters, and 
biochemical values. The organ represented 
by those pixels could have all the proper- 
ties of living tissue and permit a person to 
interact with it as if it were real. Another 
needed improvement is incorporating 
smell and sound in surgical VR. The large 
area of the cerebral cortex used for smell 
suggests that smell can be used to advan- 
tage in simulation. 

More cooperation is needed for virtual 
teaming, which allows widely separated 
medical specialists to collaborate on a 
single patient as though they were in the 
same operating room. 

VR-aided laparoscopic surgery poses 
unusual challenges to regulators, adminis- 
trators, and health professionals. 
Historically, the medical community has 
accepted a lag time of twenty to thirty 
years between lab development of a 
technique and its broad use by doctors or 
surgeons. But because of the increasing 
integration of surgical VR with advances in 
fast-moving commercial IT markets, 
surgical innovations are occurring faster 
than traditional clinical evaluation and 

implementation— much less regulatory 
review— have traditionally moved. The lag 
threatens to slow the fielding of new 

Meanwhile, market forces in the United 
States alone promise potentially extraordi- 
nary growth for telesurgery and VR-aided 
minimally invasive surgery."*' The most 
eager consumers for such procedures are 
members of the large, aging baby-boom 
population that will demand high-quality, 
leading-edge medical care even in a capita- 
tion-driven marketplace. 

Telesurgery will allow domestic surgeons 
and clinics to create lucrative overseas 
practices, as well as practices in remote 
areas of the United States. 

In short, VR-aided surgery will continue 
to benefit from advances in simulation, 
VR, displays, sensors, actuators, and high- 
bandwidth data links. Market forces 
encouraging wider use of minimally 
invasive surgery and its extension to more 
demanding medical problems will create a 
critical mass of technologists, medical 
entrepreneurs, and health insurers who 
can integrate commercial ITs into highly 
profitable systems. 

Medicine has taken its first steps into the 
next millennium. 


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Microsurgical Robot." 

RICHARD M. SATAVA is a Professor of Surgery at the 
Yale University School of Medicine. Until recently, he 
was a Professor of Surgery in the Army Medical Corps 
assigned to General Surgery at Walter Reed Army 
Medical Center, Special Assistant in Advanced 
Technologies at the U.S. Army Medical Research and 
Materiel Command, and to research at the Defense 
Advanced Research Projects Agency. He graduated from 
medical school at Hahnemann University of 
Philadelphia, interned at the Cleveland Clinic, and 
performed a surgical residency at the Mayo Clinic and a 
fellowship with a Master of Surgical Research at Mayo 
Clinic. He serves on the White House Office of Science 
and Technology Policy, the Committee on Health, Food 
and Safety, as well as the Emerging Technologies, 
Resident Education, and Informatics committees of the 
American College of Surgeons. His scholarship in 
surgical education and surgical research includes more 
than 125 publications and book chapters in diverse areas 
of advanced surgical technology. 

SHAUN B. JONES is the Program Manager for 
Unconventional Pathogen Countermeasures in the 
Biological Warfare Defense Program at the Defense 
Advanced Research Projects Agency. He is on active duty 
in the United States Navy and Assistant Professor of 
Surgery at the National Naval Medical Center (NNMC) 
and the Uniformed Services University of the Health 
Sciences (USUHC). After earning his medical degree at 
the USUHC, he completed a residency in otorhinolaryn- 
gology at the NNMC and a resident research fellowship 
at the Center for Biologies Evaluation and Research of 
the Food and Drug Administration. He is a Diplomate of 
the American Board of Otolaryngology and a Fellow of 
the American Academy of Otorhinolaryngology-Head and 
Neck Surgery. An internationally recognized authority on 
advanced surgical technologies and biological warfare 
defense, he also serves on a variety of Department of 
Defense panels, including the Military Health Services 
System 2020 Biotechnology and Nano Technology Study 

64 Medicine Beyond the Year 2000 

Use of a Mock Trial Simulation to 
Enhance Legal Medicine Education for 
Medical Students 

Theodore R. LeBlang 

The importance of legal medicine edu- 
cation for medical students has been a 
noteworthy theme in the literature for 
more than forty years. As early as 1952, the 
Committee on Medicolegal Problems of 
the American Medical Association stated 
its belief that "in the practice of medicine, 
no physician can avoid contact with the law 
and that no medical student should be per- 
mitted to receive his degree without 
instruction in his legal duties to his 
patients, community, and government."' 
That thinking has been consistently 
reaffirmed by commentators since the 
early 1950s. Moreover, the wisdom of 
teaching medical students about legal med- 
icine is seldom challenged seriously today. - 
In emphasizing the importance of 
including the study of the humanities in 
medical education, Jordan Cohen, presi- 
dent of the Association of American 
Medical Colleges, recently explained that 
"legal reasoning and the study of the legal 
system should make the physician a better 
advocate for the patient and a more knowl- 
edgeable participant in public debate on 
issues of health care services."^ In that 
regard, commentators have emphasized 
that the first goal of teaching legal 
medicine should be to enhance physician 
effectiveness in clinical medicine; the 

second goal should be to improve the 
ability of physicians to participate 
meaningfully in the administration of 
justice.^ In the latter context, it has been 
recognized that legal medicine education 
can meaningfully influence physician 
attitudes toward law, the legal system, and 
the courts, thus fostering the type of 
productive working relationship between 
physicians and attorneys that benefits both 
patients and physicians.^ 

Against the background of those consid- 
erations, the study of legal medicine has 
become more common in medical schools 
throughout the United States. Of 109 
medical schools responding to a survey 
conducted in 1992, ninety indicated that 
they were teaching legal medicine as a 
required or elective part of their 

At Southern Illinois University (SIU) 
School of Medicine, legal medicine 
teaching began in the mid-1970s as part of 
the Program of Law and Medicine 
(Program), which is based in the 
Department of Medical Humanities. 
Program coursework is comprehensive and 
well developed and makes use of various 
teaching modalities, including lectures, 
seminars, case-based tutor group discus- 
sions, and simulated patient encounters. 

CADUCEUS ♦ Autumn 1997 ♦ Vol. 13, No. 2 

Perhaps the highlight of the required 
curriculum in legal medicine is the mock 
trial reenactment of the landmark Illinois 
case Darling v. Charleston Community 
Memorial Hospital. The mock trial 
concludes the formal program of required 
undergraduate instruction in legal 
medicine and is viewed as an essential 
adjtinct to a full and complete legal 
medicine learning experience. Since 1977, 
all School of Medicine students have been 
required to participate in that important 
courtroom simulation. 

Before discussing the mock trial in 
greater detail, it is important to place the 
learning experience in context. Thus, a 
description of the Program of Law and 
Medicine follows, with emphasis on its 
core content. 

Legal Medicine Coursework 

The Program of Law and Medicine, which 
began in the mid-1970s, is an academic 
program based in the Department of 
Medical Humanities. Although teaching 
activity forming part of the various pro- 
grams in the department is integrated 
throughout the four-year curriculum, 
required instruction in legal medicine is 
concentrated during the clinical clerkship 
year. It is at that time that students rotate 
through clerkships representing the major 
medical specialties. Students also partici- 
pate in the multidisciplinary Medical 
Humanities clerkship. 

The Department of Medical Humanities 
offers a curriculum designed to provide 
students with core knowledge in the 
humanities, emphasizing application of the 
content and methodologies of humanities 
disciplines to the practice of medicine. 
Substantive areas of teaching emphasis 
include ethics, health policy, law, medical 
history, philosophy, and psychosocial care. 

The four-week Medical Humanities clerk- 
ship is divided into two segments— Medical 
Humanities A and Medical Humanities B. 
Each segment lasts two weeks. 

Medical Humanities A is delivered 
during the junior year and focuses on the 
physician-patient relationship. Issues of 
confidentiality and privacy, informed 
consent, standards of care (malpractice), 
withholding/ withdrawing life-sustaining 
treatment, assisted death, palliative care, 
organ donation, physician-patient commu- 
nication, and psychosocial care are 
addressed in the context of lectures, panel 
discussions, case conferences, tutor group 
activities, and simulated patient interac- 
tions. Throughout the clerkship, teaching 
emphasis is placed on strengthening the 
physician-patient relationship. 

Medical Humanities B is delivered early 
in the senior year and is comprised of two 
content areas: the physician's role in the 
administration of justice and the physi- 
cian's role in society, with emphasis on 
current changes in health care delivery. 
During the first part of the clerkship, 
students are exposed to an overview of the 
judicial process as well as the manner in 
which physicians serve as expert witnesses 
in civil and criminal trial proceedings. 
Systems of medical-legal investigation also 
are discussed, with emphasis on forensic 
medicine. Students further explore the 
controversy surrounding physician partici- 
pation in capital punishment. Finally, a 
mock trial is staged to permit students to 
observe the trial process in a courtroom 
setting. During the second part of the 
clerkship, students examine a variety of 
important issues relating to health care 
delivery in the United States. Those issues 
include the following: economic considera- 
tions bearing upon health care delivery, 
health care financing, access to and avail- 

66 Use of a Mock Trial Simulation 

ability of health care, the changing 
accountability of physicians in an evolving 
health care system, and clinical, ethical, 
legal, and policy aspects of managed care. 

Educational activities in the Program of 
Law and Medicine are mastery based, with 
learning objectives that are designed to 
convey to each student relevant faculty 
expectations. Learning objectives are 
contained in modules, which are the basic 
learning components of the curriculum. 
Modules are self-contained curriculum 
units, wherein faculty designate specific 
learning objectives, required and recom- 
mended learning activities, and criteria for 
successful completion. 

Presentation of legal medicine modules 
during the clerkship segment of the 
curriculum allows students to become 
familiar with important legal principles at 
a time when those principles are particu- 
larly relevant to their clinical activities. 
Within the framework of the four-week 
Medical Humanities clerkship, fourteen of 
thirty-five learning modules focus entirely 
or in pertinent part on issues arising at the 
interface of law and medicine. In addition 
to the modules that form the Medical 
Humanities clerkship, numerous addi- 
tional modules focus on issues that are 
uniquely relevant to the medical specialties 
of obstetrics and gynecology', pediatrics, 
psychiatry, and internal medicine. Those 
modules are integrated directly into the 
respective clinical clerkships. 

In the Obstetrics and Gynecology clerk- 
ship, one module focuses on legal aspects 
of abortion. In the Pediatrics clerkship, 
integrated modules focus on legal aspects 
of child abuse and neglect, parent-child 
conflicts in adolescent medicine, and limits 
on parental authority to make decisions 
involving medical care for young children. 
In the Psychiatry clerkship, a module 

focuses on issues involving the following 
topics: civil commitment and patients' 
rights following involuntary hospitaliza- 
tion; concepts of insanity, competency, 
and testamentary capacity; confidentiality 
and privacy within the psychiatrist-patient 
relationship; and negligence issues, with 
emphasis on potential areas of liability, 
including the failure to warn third parties 
of a patient's dangerous propensities. In 
the Internal Medicine clerkship, a multidis- 
ciplinary module on domestic violence 
focuses on clinical, legal, and social consid- 
erations relating primarily to partner 
abuse. Thus, throughout the clinical clerk- 
ship segment of the undergraduate 
curriculum, students participate in numer- 
ous required learning modules addressing 
important issues in legal medicine. The 
final learning experience in this sequence 
of legal medicine modules is the mock 
trial. Use of the mock trial as a conclusion 
to Program of Law and Medicine instruc- 
tion enhances the overall legal medicine 
learning experience. 

Mock Trial 

Viewed as an essential component of legal 
medicine instruction at SIU School of 
Medicine, a mock trial is staged to permit 
students to observe and participate in the 
trial process in a courtroom setting. It 
involves a three-and-a-half-hour reenact- 
ment of Darling v. Charleston Community 
Memorial Hospital. Perhaps one of the 
most-often-cited cases in the United States 
involving malpractice liability of a hospital, 
the case is rich with facts that trigger pas- 
sionate responses on the part of medical 
students. The case involves a lawsuit 
brought on behalf of Dorrence Kenneth 
Darling II to recover damages arising out 
of a below-the-knee amputation performed 
on his right leg. 

Theodore R. LeBlang 67 

Under the facts of the case, on 
November 5, 1965, DarUng, a student at 
Eastern Illinois University, sustained a 
broken right leg while playing defensive 
left halfback as a member of the Eastern 
Illinois University football team. Darling 
was taken to the emergency room of 
Charleston Community Memorial 
Hospital, at which time Dr. John 
Alexander, the on-call physician, was 
contacted to come to the hospital to treat 
him. A comminuted fracture of the right 
tibia and fibula was diagnosed and, with 
the assistance of hospital staff. Darling's 
leg was set in a cast. Thereafter, during the 
period of his hospitalization, from 
November 5 through November 19, 
Darling's condition deteriorated, eventu- 
ally necessitating transfer to Barnes 
Hospital in St. Louis. 

During the first three days of hospital- 
ization, the plaintiff complained of pain 
constantly and nurses' notes indicated that 
the foot of the injured limb became 
swollen and dark in color. On November 6, 
Alexander cut a "notch" in the cast around 
the toes and, on November 7, when the 
plaintiff complained of loss of feeling in 
his toes, Alexander cut the cast approxi- 
mately three inches up from the foot. On 
November 8, when it was evident that the 
foot and toes were still swollen and painful, 
Alexander split the cast in its entirety. 
Subsequently, during the period from 
November 9 through November 19, 
complaints of severe pain continued, the 
leg began to develop a foul odor, and it 
became gangrenous. 

On November 19, Darling was trans- 
ferred by ambulance to Barnes Hospital, 
where he came under the care of Dr. Fred 
Reynolds, head of Orthopedic Surgery at 
Washington University School of Medicine. 
DarHng continued as a patient for approxi- 

mately one month and was discharged 
home on December 16. He was readmitted 
to Barnes Hospital on December 27 for a 
two-day stay and then subsequently 
readmitted on January 16. Approximately 
three weeks later, after all efforts to treat 
the gangrenous condition of Darling's leg 
were unsuccessful, it was amputated at a 
point below the knee. 

A malpractice lawsuit containing 
numerous allegations of negligence was 
subsequently initiated against Alexander 
and Charleston Community Memorial 
Hospital. Prior to trial, Alexander settled 
the case for $40,000. Darling and his 
father proceeded to trial against the 
hospital as the only remaining defendant 
in the case. Following a two-week jury trial, 
a verdict was rendered in favor of the 
Darlings in the amount of $150,000. An 
appeal was taken during which the court 
focused attention on the hospital's asser- 
tion that it should not be found liable on 
the basis that it had no independent duty 
to oversee the care and treatment provided 
to the patient. Disagreeing with that asser- 
tion, the court emphasized that present- 
day hospitals do considerably more than 
furnish facilities for medical care and treat- 
ment. They employ large numbers of 
persons, charge patients for medical care 
rendered, and undertake collection for 
such services. Moreover, patients who avail 
themselves of hospital facilities expect that 
the hospital will attempt to cure them. 
Thus, as a matter of law, the court 
concluded that hospitals have independent 
articulable duties and responsibilities with 
respect to care and treatment of patients. 

Further appeal to the Illinois Supreme 
Court resulted in affirmation of the jury 
verdict against the hospital. The state 
supreme court concluded that the verdict 
was fairly premised upon any of the 

68 Use of a Mock Trial Simulation 

In the United States District Court for the Central Distiict of Illinois, cotinselfor the defendant. Charleston 
Community Memorial Hospital, undertakes direct examination of a School of Medicine faculty member portraying 
the role of hospital administrator Wayne Annis. Judge Richard H. Mills presides. 

following violations of the applicable 
standard of care: 

[Failing] to have a sufficient number of trained 
nurses for bedside care of all patients at all 
times capable of recognizing the progressive 
gangrenous condition of the plaintiffs right 
leg, and of bringing the same to the attention 
of the hospital administration and to the 
medical staff so that adequate consultation 
could have been secured and such conditions 
rectified; . . . [and failing] to require consulta- 
tion with or examination by members of the 
hospital surgical staff skilled in such treatment; 
or to review the treatment rendered to the 
plaintiff and to require consultants to be called 
in as needed/ 

Given the fact that the Darling case 
involved a two-week jury trial, extensive 
witness testimony is available upon which 
to base development of an interesting 
mock trial reenactment. To provide a 

realistic forum within which to conduct the 
trial, the courtroom of the United States 
District Court for the Central District of 
Illinois is used. With its rich, traditional, 
dark wood paneling, this stately courtroom 
is visually impressive to medical students 
and consistent with their preconceived 
notions of a "classic" courtroom environ- 

Presiding over the mock trial is a volun- 
teer community trial judge who serves as a 
member of the adjunct faculty of the 
Department of Medical Humanities. 
Through the years, four judges have 
served: United States District Judge J. 
Waldo Ackerman; Illinois Supreme Court 
Justice Benjamin K. Miller; United States 
District Court Judge Richard H. Mills; and 
Chief Circuit Court Judge Sue E. 
Myerscough of the Seventh Illinois Judicial 
Circuit. To ensure that the mock trial does 

Theodore R. LeBlang 69 

not conflict with other ongoing judicial 
activities, it is scheduled to occur from 
7:15 P.M. to approximately 10:45 P.M., as an 
evening activity during the clerkship. 

Other participants in the mock trial 
include four community trial attorneys, 
who are recognized for their expertise in 
prosecuting and defending medical 
malpractice cases. Two of the attorneys are 
assigned to represent the plaintiff, and two 
are assigned to represent the defendant; all 
are members of the adjunct faculty of the 
department. Involvement of multiple attor- 
neys during the mock trial provides 
medical students with exposure to a diver- 
sity of courtroom styles, tactics, and 
demeanor. Other School of Medicine 
faculty, residents, and administrators 
volunteer to play the remaining mock trial 
roles as follows: the plaintiffs. Darling and 
his father; Alexander, the treating physi- 
cian; a hospital nurse, Anna Myers, who 
was integrally involved in Darling's care; 
Reynolds, a physician from Barnes 
Hospital, the plaintiff's expert witness; 
Wayne Annis, hospital administrator for 
the defendant, Charleston Community 
Memorial Hospital; and Mack HoUowell, a 
physician on staff at the hospital and the 
defendant's expert witness. All mock trial 
participants are provided with a 
compendium of case materials to prepare 
for the proceeding. A brief rehearsal 
occurs immediately prior to the mock trial 
in the judge's chambers at the federal 
district court. 

The mock trial is conducted in a serious 
and formal manner and is designed to 
exemplify important aspects of the trial 
proceeding. Court is first called into 
session by the clerk of the court with the 
typical formalities that attend such a 
proceeding. Subsequently, throughout the 
mock trial, the clerk administers the tradi- 

tional oath to jurors and to all witnesses. 

The trial begins with voir dire (examina- 
tion) of jurors, to exemplify the jury selec- 
tion process. Jurors consist of medical 
students who self-select to occupy the 
fourteen seats in the jury box. The 
remaining students, who constitute the 
balance of the entire senior class, occupy 
courtroom seats that are typically filled by 
public observers. The jury selection 
process, although abbreviated, includes an 
interchange that results in the dismissal of 
a juror who the court (or counsel) deter- 
mines is unable to be fair and impartial in 
deliberating about the facts of the case. 

Following voir dire, one attorney for the 
plaintiff and one attorney for the defense 
make opening statements. Thereafter, the 
plaintiff's witnesses are examined and 
cross-examined in a manner consistent 
with applicable rules of civil procedure. 
Various props are utilized as evidence 
exhibits, including the following: rules and 
regulations of the Illinois Department of 
Public Health under the Hospital 
Licensing Act, relevant standards for 
hospital accreditation promulgated by the 
Joint Commission on Accreditation of 
Hospitals (now JCAHO), and hospital 
medical records. Various textbooks also 
are used for purposes of cross-examina- 

Attorneys are asked to interpose appro- 
priate objections throughout the course of 
examination and cross-examination of 
witnesses in an effort to portray to 
students the types of objections that may 
be made during the course of a trial. 
Rulings are then made by the judge, often 
with appropriate explanation to enhance 
the learning experience. Occasional 
sidebar meetings of attorneys at the 
judge's bench also are staged to enhance 
the reality of the simulation. 

70 Use of a Mock Trial Simulation 

After presentation of the plaintiff's 
witnesses, there is a brief recess, which is 
followed by defense presentation of 
witnesses. Again, direct- and cross-exami- 
nation are conducted by attorneys consis- 
tent with standard courtroom procedure. 
Following presentation of defense 
witnesses, the parties rest. Due to applic- 
able time constraints, no rebuttal testi- 
mony is offered. 

Closing argiunents follow, during which 
one attorney for the plaintiff and one 
attorney for the defense address the jury in 
a manner consistent with typical closing 
arguments, albeit abridged. Pertinent jury 
instructions are then read to members of 
the jury by the trial judge, who directs the 
jurors to commence deliberations. 
Concluding remarks are then offered by 
the judge, and students are given an 
opportunity to vote in favor of or against 
the plaintiff or defendant by show of 
hands. A question-and-answer session 
follows, during which students may pose 
questions to the judge, the trial attorneys, 
and Medical Humanities faculty who are 

Pedagogical Considerations 

It has been recognized that legal medicine 
education in medical schools must be 
innovative and creative and should be 
presented through a multitude of formats.^ 
Various types of simulations have been 
highlighted as affording excellent opportu- 
nities to maximize the effectiveness of 
legal medicine teaching.^ Mock trials have 
been described as extremely useful 
teaching tools that can assist medical 
students in understanding legal medicine 
as well as the important role of the physi- 
cian in the administration of justice.^" In 
1994, Stuart Levine and Henry Pinsker 
observed that although use of a mock trial 

as a teaching tool in medical education has 
rarely been reported, "it is a powerful tool 
for teaching about the interface between 
medicine and the law."" Moreover, they 
observed that "malpractice cases . . . not 
only demonstrate the issues clearly, but 
they also hold the attention of the 
audience most effectively."'- 

Those observations of various commen- 
tators echo the long-held view of the 
Department of Medical Humanities that 
use of a mock trial as a conclusion to 
required legal medicine coursework for 
medical students maximizes the overall 
learning experience. It permits students to 
integrate and apply their medical-legal 
expertise in observing and analyzing a trial 

It should be emphasized that the mock 
trial is designed to be more than a passive, 
observational, learning experience.'^ To 
maximize the value of the simulation, 
students are required to undertake specific 
preparation for the courtroom proceeding 
and to participate in the simulation in an 
interactive manner. All students are 
required to write an analysis of the mock 
trial, demonstrating their ability to: (I) 
describe the fact situation of the under- 
lying litigation in the case, (2) define and 
describe the significant legal issues, (3) 
identify and describe the roles of the 
participants, and (4) identify and describe 
the components of the trial process, 
including voir dire, opening statements, 
direct- and cross-examination of witnesses, 
closing arguments, and jury instruction. 
Of greatest importance with respect to the 
written essay is the interactive nature of 
the assignment. 

Students are required, in advance of the 
mock trial, to carefully read the approxi- 
mate seventy-five-page Darling case and to 
participate in a pretrial discussion of 

Theodore R. LeBlang 71 

faculty expectations regarding applicable 
learning objectives. Further, as an 
additional part of the learning experience, 
students are required to prepare an 
approximately four-page typed analysis of 
the mock trial based upon personal obser- 
vation during the three-and-a-half hour 
simulation. Students are specifically asked 
to assume the perspective of either a juror, 
one of the trial attorneys, a particular 
witness, the plaintiff, the defendant, or the 
trial judge, and then to describe and 
analyze the trial proceeding as viewed 
through the eyes of the selected partici- 
pant. Students demonstrate, through that 
"first-person" description, an overview of 
the mock trial, highlighting occurrences of 
importance to the individual whose 
perspective they have assumed. Students 
therefore must apply their knowledge of 
the roles of the various participants in the 
mock trial while identifying and describing 
the components of the trial process that 
would be viewed as significant by the 
participant whose perspective they have 

In order to fulfill that requirement of 
the learning activity, students must be 
attentive to all occurrences during the 
mock trial and record personal notes of 
activities that they deem important in light 
of their first-person evaluation of the 
experience. Thus, the student who 
assumes the perspective of a juror, as an 
example, will likely focus broadly on the 
testimony of witnesses as well as the 
relative effectiveness of attorneys for the 
defense and the plaintiff. If a student 
assumes the perspective of an attorney, 
then the essay likely will focus more selec- 
tively upon the attorney's tactics and strate- 
gies during the trial, with emphasis on 
approaches used during direct- and cross- 
examination of witnesses. Students 

assuming the perspective of the plaintiff or 
the defendant will focus on the effective- 
ness of witness testimony and the attor- 
neys' opening statements and closing 
arguments. Students who assume the 
perspective of the trial judge will focus 
more on the responsibilities of the judge 
to ensure fairness, to properly educate the 
jury about its responsibilities, and to rule 
properly on objections and motions. 
Because medical students have completed 
all required coursework in legal medicine 
at the time they undertake the essay, they 
are able to rely upon a considerable 
database of statutory law, common law, 
and rules of courtroom procedure in 
completing their analyses. 

During the past twenty years, students 
have been particularly creative in their 
approach to the essays, evidencing a 
surprisingly high degree of sophistication 
in the context of assuming the various 
perspectives of all participants in the mock 
trial simulation. Moreover, students have 
indicated that they gained more from the 
learning experience than if they had 
functioned simply as passive observers. 

Commentators have observed that there 
is strong evidence that students give high 
marks to mock trials as an experiential 
approach to learning about legal issues. ^^ 
That is consistent with the views expressed 
by medical students who have participated 
in the Department of Medical Humanities 
mock trial. Written feedback from students 
has been quite favorable over the years. Of 
particular interest is a more focused set of 
student feedback obtained in September of 

In that year, students were asked to 
complete a reasonably detailed feedback 
form in addition to the general feedback 
form utilized to evaluate the overall clerk- 
ship. Among the questions posed to 

72 Use of a Mock Trial Simulation 

CoiuLsel for the plaintiff presents closing arguments to medical student jurors. At defense counsel table, in 
foreground, is hospital administrator Annis. Co-counsel for the plaintiff, along with the resident and medical school 
faculty member portraying the roles ofDoirence Kenneth Darling II and his father, are seated at plaintiffs counsel 
table near jury. 

Students were the following: 

1. Did attending the mock trial improve 
your imderstanding of material on law and the 
legal system to which you were previously 
exposed in the cumculum? If so, describe how. 

2. Did attending the mock trial improve 
your understanding of the trial process and the 
physician's role in the administration of 
justice? If so, describe how. 

3. What was your overall reaction to the 
mock trial learning experience? In general, 
how did it compare with your other learning 
experiences at the School of Medicine? 

Because student feedback was provided 
in narrative form, subjective categorization 
of responses was required in order to offer 
a meaningful summary. However, given 
that caveat, the author views the following 
summary as fairly portraying student 

In response to the first question, fifty-six 
out of sixty-three respondents indicated 
that the mock trial clearly improved their 

understanding of law and the legal system. 
Three indicated that it improved their 
understanding somewhat, and four 
indicated that it improved their under- 
standing minimally or not at all. In 
response to the second question, fifty-three 
out of sixty-one respondents indicated that 
the mock trial clearly improved their 
understanding of the trial process and the 
physician's role in the administration of 
justice. Four indicated that it somewhat 
improved their understanding, and four 
indicated that it improved their under- 
standing minimally or not at all. In 
response to the third question, forty-eight 
out of fifty-nine respondents rated the 
mock trial as a better-than-average learning 
experience (of the forty-eight, thirty-four 
rated it as excellent or very good, and six 
observed that it was one of the best 
learning experiences while in medical 
school). Again, it should be emphasized 
that the summaries of student feedback are 
based upon subjective categorization of 

Theodore R. LeBIang 73 

general written comments offered in 
response to the questions noted above. 
Nevertheless, the feedback offers useful 
insights regarding the overall success of 
the mock trial simulation as a legal 
medicine learning experience. 


The mock trial represents an extremely 
important and valuable use of simulation 
in the context of educating medical 
students about legal medicine. It affords 
medical students an opportunity to 
evaluate the application of important legal 
principles within the framework of a 
medical malpractice case being adjudi- 
cated in a court of law. Moreover, it 
enhances student understanding of the 
important role of the physician in the 
administration of justice as well as the 
manner in which the legal system operates. 
That is particularly important in view of 
the fact that many physicians will be called 
upon throughout their careers to testify as 
witnesses in a variety of civil and criminal 

Testimony often will be required in 
situations where patients have been 
injured, whether as a result of work-related 
accidents, automobile collisions, product- 
related injury, domestic violence, sexual 
assault, or child abuse. Testimony also may 
be required in a variety of other legal 
proceedings where patient interests are 
involved, such as will contests, child 
custody disputes, and civil commitment 
proceedings. Because of the numerous 
areas where law and medicine converge, 
physicians may anticipate being drawn into 
a variety of patient-related disputes 
wherein a legal resolution may be 
required. ^^ Furthermore, legal medicine 
education can meaningfully influence 
physician attitudes toward law, the legal 

system, and the courts, thereby engen- 
dering a more positive working relation- 
ship between physicians and attorneys that 
will enhance the physician-patient relation- 
ship and permit the physician to function 
as an important advocate on behalf of a 
patient's best interests.*^ 

Against the background of those consid- 
erations, incorporation of a mock trial 
simulation in a curriculum designed to 
expose medical students to legal medicine 
education has tremendous pedagogical 
value. It is a distinctive educational 
technique that deserves to be more widely 
employed,'^ and medical schools are urged 
to consider not only the approach outlined 
in this article but to consider other innova- 
tive strategies for simulating physician 
participation in the administration of 


1. L. J. Regan, "Report of Committee on 
Medicolegal Problems: A Suggested Course in 
Legal Medicine for Medical Schools," /AMA 150 
(1952): 716. 

2. Marshall B. Kapp, "Teaching Legal 
Medicine in Medical Schools," /oj/rwa/ of Legal 
Medicine 8 (1987): 94-103; Barbara B. Blechner, 
Christie L. Hager, and Nancy R. Williams, "The 
Jay Healy Technique: Teaching Law and Ethics to 
Medical and Dental Students," American Journal of 
Law and Medicine 20 (1994): 439-55. 

3. Jordan Cohen, "The Humanities and 
Medical Education," Academic Medicine 70 (1995): 

4. Peter L. Williams and William Winslade, 
"Educating Medical Students about Law and the 
Legal System," Academic Medicine 70 (1995): 

5. Theodore R. LeBlang et al., "The Impact of 
Legal Medicine Education on Medical Students' 
Attitudes Toward Law," Journal of Medical 

74 Use of a Mock Trial Simulation 

Education 60 (1985): 279-87; Kapp, "Teaching 
Legal Medicine," 96. 

6. Williams and Winslade, "Educating Medical 
Students," 777, 780. In a more recent survey of 
internal medicine chief residents, 92 percent of 
tiiose responding (n = 159) indicated that medical 
legal issues played an important role in medical 
practice and 76 percent felt that legal medicine 
education should form part of the undergraduate 
medical education curricuhmi. Chad D. Kollas, 
"Exploring Internal Medicine Chief Residents' 
Medicolegal Knowledge," Jo ur« a/ of Legal Medicine 
18 (1997): 47-61. 

7. Darling v. Charleston Community Memorial 
Hospital, T.', 111. 2d :^26. 211 N.E.2d 253, 258 

8. Kapp, "Teaching Legal Medicine," 98. 

9. Williams and Winslade, "Educating Medical 
Students," 783. 

10. Teny Lewis and Suzanne Prior, "With Mock 
Trials, Students Learn by Doing," Florida Bar 
Journal 67 (Oct. 1993): 30-34; Richard Smith, 

"Losing a Mock Trial to Make a Difficult Clinical 
Decision," British Medical Journal 305 (1992): 
1284-87; Michael Langford, "The Moot Court in 
Teaching Bioethics," Nurse Education Today 10 
(1990): 24-30; Fay Rozovsky, "Symposium on 
Teachhig Legal Medicine: Introduction," Journal 
of Legal Medicine 8 (1987): 91-93. 

11. Stuart Levine and Henry Pinsker, "The 
Mock Trial in Psychiatric Staff Education," 
Bulletin of the American Academy of Psychiatry and 
the Law 22 (1994): 127-32, quotation from 131. 

12. Ibid., 131. 

13. See Meg Wilkes Karraker, "Mock Trials and 
Critical Thinking," College Teaching 41 (1993): 
134-37. Karraker observes that the trial merely 
will ser\e as recreation unless the simulation is 
prefaced with a clear discussion of the learning 
objectives and is followed by a conscientious 
debriefing. She further states that such a 
"debriefing can take the form of deliberation by 
the JU17 and oral or written accounts prepared by 
reporters attending the trial, or a class discussion 
led by the instructor" (136). 

14. John J. Whyte, "Mock Ethics Trial for 
Medical Students and Law Students," Academic 
Medicine 68 (1993): 844; Sherry Warden et al., 
"The Effect of a Mock Trial on Nursing Students' 
Ability to Make Clinically Sound Legal 
Judgments," Nurse Educator 19 (May/June 1994): 


15. Kapp, "Teaching Legal Medicine," 95. 

16. LeBlang et al., "Impact of Legal Medicine 
Education," 284-86. 

17. Levine and Pinsker, "Mock Trial in 
Psychiatric Staff Education," 127. 

THEODORE R. LEBLANG is Professor of Medical 
Jurisprudence and Chairman of the Department of 
Medical Humanities, Director of the M.D./J.D. Dual 
Degree Program, and Director of the Program of Law 
and Medicine at Southern Illinois University School of 
Medicine. He is editor of the Journal ot Legal 
Medicine, coauthor of Tl)e Law of Medical Practice in 
Illinois, and annotator for the American Medical 
Association Code of Medical Ethics: Current Opinions 
with Annotations. Among his other recent publications 
are "Current Tort Law Overview, ' in the American 
College of Surgeons Professional Liability/Risk 
Management Manual for Surgeons (1997) and 
"Informed Consent and Alzheimer Disease Research: 
Institutional Review Board Policies and Practices, ' in 
Alzheimer Disease: From Molecular Biology to 
Therapy (^9%). 

Theodore R. LeBlang 75 

Picture Credits 

Page 4: Phyllis Barrows, Springfield, 111., 
courtesy of the Author. 

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